Download Cardiac Dysrhythmia following Pneumonectomy

Cardiac Dysrhythmia
Pneumonectomy*
Clinical
Correlates
MichaelJ.
Krowka,
VictorF
Trastek,
PhilipE.
Bernatz,
and Prognostic
M.D.;PeterC.
M.D.,
following
Pairolero,
FC.C.P;W
Significance
M.D.,
Spencer
FC.C.P.;
Payne,
M.D.,
FC.C.P.;
Cardiac
tachydysrhythmias
occurred
in 53 (22 percent)
of
patients
undergoing
pneumonectomy.
All
patients
had preoperative
electrocardiograms
which
showed normal
sinus rhythm.
Patients
did not receive digitalis before surgery. Atrial fibrillation
was the most common
dysrhythmia
(64 percent;
34/53), followed
by supraventricular tachycardia
(23 percent;
12/53)
and atrial flutter
(13
percent;
7/53). No episodes
of ventricular
tachycardia
were
documented,
Elevated
concentrations
of cardiac
enzymes
were associated
with
12 (28 percent)
of 43 tachydysrhythmias.
Recurrent
or persistent
dysrhythmias
were
documented
in 29(55 percent)
of 53 patients despite medical
management
or electrocardioversion
(or both).
Thirty-one
percent
(9/29)
of these
patients
subsequently
died during
their hospitalization.
There was no correlation
between
standard
preoperative
pulmonary
function
tests and the
incidence
of postoperative
dysrhythmia.
In addition,
there
was
‘J’he
continuous
consecutive
236
clinical
course
and
F.C.C.P
M.D.,
no correlation
of dysrhythmia
with
postoperative
diagnoses, surgical
staging for lung cancer,
postoperative
arterial blood gas levels, or the fact that a completion
pneumonectomy
or chest wall resection
was
undertaken.
An
increased
incidence
of tachydysrhythmia
was noted
in
patients
undergoing
intrapericardial
dissections
and those
who developed
postoperative
interstitial
or perihilar
pulmonary
edema.
Twenty-five
percent
(13) of the patients
experiencing
tachydysrhythmias
died within 30 days following their pneumonectomy.
We conclude
that tachydysrhythmias
after pneumonectomy
are associated
with significant mortality,
have poor correlation
to preoperative
pulmonary
function,
and occur
more frequently
following
intrapericardial
dissection
postoperative
pulmonary
and
interstitial
edema.
in
following
pneumonectomy
may
complications
preoperative
which
have
pulmonary
poor corfunction
onstrated
tests, such as the forced vital capacity
(FVC) and forced
expired
volume
in one second
(FEV1).’
Cardiac
dysrhythmias
are well-documented
complications
follow-
terpreted
ing pneumonectomy,4
236
patients
studied
is provided
in the
the
numbers
within
parentheses
represent
involve
certain
relation
to selected
dysrhythmias
mortality,
and
in selected
have
been
associated
with
This
retrospective
analysis
as
undergoing
pneumonectomy
three-year
occurrence
period
was undertaken
of various
postoperative
preoperative
pulmonary
at the
also
records
monectomy
viewed.
both
of 244
at the
Each
before
Clinic
until
Mayo
patient
and
after
AND
consecutive
a
the
to
for patients
dysrhythmias
had
Clinic
METHODS
who
patients
from
routine
pneumonectomy,
1982 through
12-lead
underwent
early
and
at any time
pneu-
1985 were
electrocardiograms
re-
taken,
that
the time
upright
consultants.
postoperative
of the patient’s
in intensive
record
in intensive
portable
by radiologic
and
While
was
care,
chest
The
events
discharge
develop
or perihilar
care
dem-
interpreted
each
by a
patient
had
roentgenograms
data
during
or death.
following
reported
in-
include
all
hospitalization
up
A description
of the
tabulation,
where
percentages:
Sex
over
and to perioperative
significance
cardiac
postoperative
Each
who
edema
monitoring
in rhythm.
consultant.
preoperative
significant
of patients
routine
5From
the Department
ofThoracic
Diseases
and Internal
Medicine,
Section
of Thoracic
and Cardiovascular
Surgery,
Mayo Clinic
and
Mayo Foundation,
Rochester,
MN.
Manuscript
received
September
II; revision
accepted
October
14.
Reprint
requests:
Dr Krowka,
4500 San Pablo Road,
Jacksonville,
FL 32224
490
daily
evaluated.
MATERIALS
The
Mayo
cardiologic
these
to correlate
dysrhythmias
function
clinical
data. The prognostic
who
developed
postoperative
was
patients,
electrocardiographic
a change
patients
pulmonary
Female
Male
Age
Less than 50 yr
Between
51 and 69 yr
70 yr or older (9 older than 80)
Indications
Primary
lung cancer
Metastatic
disease
Inflammatory
disease
Mesothelioma
(malignant)
Lymphoma/Av
mal/broncholithiasis
Operative
notes
Right pneumonectomy
Left pneumonectomy
Completion
pneumonectomy
Intrapericardial
pneumonectomy
Previous
thoracic
irradiation
Surgical
staging
Ti
T2
T3
NO
Ni
N2
Stage
1
Stage 2
Cardiac
Dysrhythmia
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21558/ on 05/10/2017
tollowing
65 (28)
171 (72)
38 16
149 63
49 (21)
197
(83)
14 (6)
12 5)
94
4 (2
112 (47)
124(53)
28 (12
32 (14
9(4
183 (78
(11)
(61
(28
(32)
(32)
(36
(12
(61)
Pneumonectomy
(Kmwka
eta!)
Stage 3
Reoperation
within
72 hr
30-day
mortality
Intraoperative
deaths
Postoperative
deaths
The
operative
tient
were
developed
Upon
notes
was
was
patient
pH
analyzer
dioxide
arterial
tension
recurrent
oxygen
or persistent
ECGs
beyond
pressure
if they
24 hours
from
(Pa02),
again
gas
just
were
prior
documented
by
patients
showed
as
12-lead
atrial
operative
fibrillation
(N =8)
were
excluded;
resulted
Patients
in records
from
236 patients
for
did not receive
digitalis
before
surgery
purpose
of preventing
Cardiac
of the
cent)
tomy.
In
236
patients
12 (28
percent)
increases
(>2
in
and
found
levels
mented
marily
of 43
of
patterns
ECGs.
in the
those
12
patients
and
In six of the subjects,
of cardiac
dysrhythmia,
enzymes
to the
subsequent
had
docu-
nine
of the
preceded
and
in the
rhythm
dismissed
(rate
to
the devel-
rhythmia.
disturbance.
a significant
ative
medications
reasons
other
than
and were continued
when
the rhythm
were
rhythm
preoper-
that had been
administered
for
the proposed
pulmonary
resection
through
the perioperative
period
disturbances
occurred.
The initial
Table
1-Initial
Cardiac
Dysrhythmia
Recurrent
Rhythm
Frequency
Total
Atrial
fibrillation
Supraventricular
Atrial
*N =53
tDrop
in systolic
blood
pressure
more
arterial
documented
with
atrial
25 per(37) were
frequently
than
there was no clear
of dysrhythmias
blood
gas abnormalities
about
the time of dys-
hypoxemia
(Pa02<Z60
only 15 percent
disturbances,
and
factor.
(8/53)
mm
the pH of the blood
Furthermore,
was
not
was no signifi-
the
TNM surgical
monectomies,
stage of lung cancer,
completion
previous
thoracic
irradiation,
after
between
indication
there
Hg)
with
of those
cant association
rhythmia
and
or
Persistent
the development
for pneumonectomy,
of
dysthe
pneuor the
Pneumonectomy*
With
Res olved
Hypotensiont
prior
to Dismissal
Associated
with
Mortality
20 (38)
37 (70)
13 (25)
20 (69)
14 (70)
23 (62)
9 (69)
12 (23)
4 (14)
4 (20)
7 (19)
4 (31)
7 (13)
5 (17)
2 (10)
7 (19)
0
. .
.
. .
0
data
in
29 (55)
tachycardia
lkble
hospital
medication),
and 70 percent
34 (64)
tachycardia
(22 percent).
agof
53 (100)
flutter
Ventricular
the
with
occurred
Specifically,
(two),
(one)
tachydysrhyth-
and amiodatone,
as
four patients
in whom
from
controlled
and postoperative
which
could
be
six
In six of the 53 patients
developing
tachydysrhythmia,
either
digoxin
(three),
3-adrenergic
blockers
blockers
the first six
(55 percent)
which
included
with
combinations
cant rhythm
problems.
In addition,
association
between
the development
of
was associated
or calcium-channel
two
the dys(50) of the
ative interstitial
pulmonary
edema
or perihilar
pulmonary infiltrates
(Table 2). Neither
age nor preoperative
pulmonary
function
had any predictive
value in determining
who would
or who would
not develop
signifi-
pri-
remaining
within
patients
recurrent
Only
of
expected
(p<O.OOl)
in 53 percent
(17) of 32 patients
who underwent
intrapericardial
pneumonectomy
and
in 52 percent
(30) of those 58 who developed
postoper-
fraction
elevations
onset
95 percent
verapamil,
In the
Tachydysrhythmia
per-
were
MB
in systolic
Hg).
cent (13) died in the hospital,
dismissed
in normal
sinus rhythm.
documented
change
abnormalities,
of the T-waves,
compared
opment
occurred
(22
phosphokinase
of infarction,
concentrations
of the
review.
for the
53
were
fibrillation
pneumonec-
patients,
elevations
had non-Q-wave
in the configuration
preoperative
in
underwent
creatine
with
Three
Q-wave
who
(three)
this
dysrhythmias.
occurred
of
associated
percent).
patients
postoperative
tachydysrhythmia
a drop
ven-
cardioversion
was attempted,
two attempts
were successful,
and two patients
remained
in a persistent
rhythm
abnormality.
Of the 53 patients,
5 percent
ECGs
pre-
with
by
25 mm
dysrhythmia
Twenty-nine
digitalis,
quinidine,
well as cardioversion.
documentation.
in this study
had preoperative
normal
sinus rhythm.
Patients
per minute,
associated
mias
despite
maximal
therapy
gressive
medical
management
RESULTS
All
which
had
150 beats
hypotension
had an intraoperative
(both survived),
and
or
is shown
atrial
dysrhythmias
than
persistent
surgery
developed
ventricular
tachyHemodynamically,
(defined
of greater
experienced
carbon
considered
with
dysrhythmia
patients
developed
days after
surgery.
for as-
and arterial
rhythms
were
initial
any
blood
reviewed
of those
pressure
patients
rhythmia
an
For
obtained
after
(34)
no patient
developed
pneumonectomy.
(24)
the
blood
venti-
(Dss).
were
with
those
tests,
voluntary
IL 282 oximeter)
In addition,
For
occurring
percent
tricular
responses
greater
than
and 38 percent
(20) had relative
which
the arterial
the dysrhythmia
45 percent
pa-
period.
function
capacity
fibrillation
and
cardia
following
hospital
occurred
maximum
cardiac
dysrhythmia
in Table
1. Sixty-four
which
patient’s
discharge.
dysrhythmia,
and
(PaCO2).
to
diffusing
fullowing,
of pH,
the
pulmonary
FEy1,
for each
problems
postoperative
unit,
prior
FVC,
a cardiac
to, or immediately
sessment
of the
record
if complications
steady-state
developing
unit
or surgical
care
intervention
and
(IL 1302
intensive
preoperative
made
(MVV),
care
medical
to determine
subsequent
lation
intensive
or in the immediate
the
completing
assessment
levels
surgery
from
reviewed
required
patients
the
to define
during
discharge
record
and
reviewed
(27)
8 (3)
26(11)
10(38
16 (62
are numbers
of at least
of patients;
25 mm
numbers
within
parentheses
are
.
percents.
Hg.
CHEST
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21558/ on 05/10/2017
I 91 / 4 /
APRIL,
1987
491
Table
2-Clinical
Correlate8
Dysrhythmias
following
Cardiac
with
With
Parameter
Preoperative
N
Dys-
Dysrhythmia
All patients
236
thoracic
FEV<2.O
FEV>2.O
L
L
irradiation
53 (22)
183
6
58
90
17
41
This
22
68
center
nectomy
percent
of predicted
46
12
34
percent
of predicted
104
25
79
150
94
88
MVV
Mean
Dss
Age<50
Age
percent
of predicted
94
yr
51-59
yr
Age7O+yr
Postoperative
17.7
but
6
32
149
31
118
49
16
33
lung
cancer
lung
Inflammatory
cancer
197
41
156
14
3
disease
ii
12
5
Mesothelionia
7
9
3
6
Ti
(malignant)
surgical
stage
21
5
16
T2 surgical
stage
112
22
90
T3 surgical
stage
50
12
38
from
on to develop
after
The
surgery.
mia did occur more
with interpericardial
terstitial
frequently
dissections
or perihilar
pulmonary
surgical stage
57
12
45
Our
N2
surgical stage
15
Stage
2
112
22
90
Stage
3
51
12
39
Pa02<6OmmHg
53t
8(15)
.
pH<7.35
53t
6 (ii)
.
pH>7.45
53t
13 (25)
.
Completion
Chest
pneumonectomy
wall
resection
Intrapericardial
Interstitial
or perihilar
30-day
=
236.
Table
blood
19.80;
§Chest
x-ray
98.60;
x21215
need
data
are
numbers
8
4
9
32
lfl
15
58
3011
2811
26
13T
1311
20
numbers
gas levels
unless
dysrhythmia
within
occurred.
p<O.OOJ.
rized
between
incidence
in Table
major
film.
p<O.OOl.
The
(26/236).
30-day
There
wall
resections.
mortality
in the series
were ten intraoperative
was II percent
deaths
and 16
postoperative
deaths.
Table
3 summarizes
data. Intraoperative
deaths
were not caused
relevant
by distur-
bances
in cardiac
rhythm;
hemorrhage
was the major
problem.
Of the postoperative
deaths,
81 percent
(13/16) were associated
with or preceded
by tachydysrhythmias,
and 69 percent
persistent
or recurrent
(9/13)
of those
dysrhythmias.
patients
Nine
series
4.
assessing
and
had
(31 per-
cent) of 29 patients
with recurrent
or persistent
tachydysrhythmia
died during
hospitalization.
Twenty-five
percent
(13) of the 53 patients
developing
tachydysrhythmias
died,
compared
to 7 percent
(13/183)
who
died without
dysrhythmias
(p<O.OO1).
Fifty-four
per-
of dysrhythmia
from
disturbances
commonly),
flutter.
The
to eliminate
chest
largest
dysrhythmia
4 ranged
rhythm
(most
atrial
p<O.O0l.
to complete
the
dysrhythmias
in Table
summarized
the
mortality
in
Keagy
et al,2 in which
they reported
a similar
30-day
mortality;
however,
they did not correlate
the onset of
rhythm
disturbances
to subsequent
mortality.
The
not assessed
represent
cardiac
with
significant
rhythm
disturbances
subsequently
died, a higher
percentage
than the accepted
mortality
for pneumonectomy.
Statistics
on 30-day
mortality
were not available
in any other
study
except
that of
13
patients;
data
relationship
28
of
was
patients
who underwent
pneumonectomy.
Of those
series
which
correlated
the incidence
of dysrhythmia
with subsequent
mortality,
23 to 33 percent
of patients
are percentages.
tArterial
tx2
edemal
mortality
parentheses
2_
dissection
in mortality
edema.
Ni
52
of morsinus
than expected
in those
and postoperative
in-
47
5
tachy-
degree
normal
difference
11
16
referral
or recurrent
a greater
maintained
58
20
a tertiary
persistent
experienced
those
who
surgical stage
68
492
analysis
NO
1
re-
present
that patients
who underwent
pneumodid not receive
digitalis
before
surgery
Previous
studies
concerning
following
pneumonectomy
are
Stage
and
were
significant.
Tachydysrhythmia,
regardless
of ventricular response,
appeared
to have no apparent
association
with preoperative
pulmonary
function,
surgical indication, or TMN staging
of lung cancer.
Tachydysrhyth-
correlates
Metastatic
went
rhythms
Diagnosis
Primary
hypotension,
of dysrhythmia
retrospective
showed
who
dysrhythmias
tality
than
18.8
38
hypoxemia,
or persistence
to death.
DIscuSsIoN
3
MVV<80
prolonged
(78)
9
MVV>80
Mean
currence
prior
correlates
Previous
(7/13)
of death,
Without
rhythmia
of dysrhythmias
occurred
within
96 hours
of
If dysrhythmia
occurred
prior to 72 to 96 hours
cent
death.
Pneumonectomy*
in patients
summa-
9 to 29 percent,
being
atrial
with
the
fibrillation
supraventricular
tachycardia,
and
data in these studies
were reviewed
ventricular
the inclusion
of patients
with premature
complexes
or premature
atrial complexes
as
part
definition
of the
pneumonectomy.
tremely
uncommon
occurred
erative
of cardiac
in our study,
Q-wave
changes
associated
cardiac
The
enzymes.
only study
or
even
studies
with
non-Q-wave
with
that
following
were
exand none
the onset
of periop-
electrocardiographic
elevated
concentrations
significantly
lactic digitalization,
that
a decreased
incidence
prophylactic
of rhythm
mortality.
dysrhythmia
Ventricular
tachycardias
in the studies
reviewed,
addressed
of Shields
and
of dysrhythmia
of
prophy-
Ujiki,9
showed
following
digitalis
but did not discuss
the incidence
disturbances
as they related
to subsequent
Our study
is different
from
the previous
in that
Cardiac
most
of our
Dysrhythmia
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21558/ on 05/10/2017
patients
following
had
Pneumonectocny
continuous
(Krowka
eta!)
Table
Group
3-Clinical
Data
of Those
Who Died
within
30
Days following
Postoperative
and
Case/Age
Surgical
(yr)
Indication,
Day
Procedure
cell
typet
or Stage
Pneumonectomy*
Recurrence
of Dys-
Hypo-
rhythmiafDeath
or
tension
Persistence
Commentsf
Intraoperative
1/66
L squamous
T3N2
2/68
R adenocarcinoma
Completion
3/39
R metastatic
Wilms’
4/80
squamous
6/54
L metastatic
R squamous
L large cell
7/74
R Lymphoma/BP
5/63
#{149}
. .
.
.
.
.
.
Arterial
.
hemorrhage
Hemorrhage
Hemorrhage
#{149}
. .
. . .
.
.
Completion
#{149}
. #{149}
.
.
.
.
.
.
Arterial
Completion
#{149}
. .
.
.
.
.
.
.
Hemorrhage
Completion
#{149}
. .
. . .
.
.
.
tumor
SVC
(diffuse)
hemorrhage
hemorrhage
Arterial
hemorrhage
fistula
8/53
9/75
10/64
R adenocarcinoma
R squamous
R squamous
Completion
#{149}
. .
.
.
.
.
.
.
Hemorrhage
T3NO
#{149}
. .
.
.
.
.
.
.
Arterial
(diffuse)
T3N2
#{149}
.
.
.
. .
.
.
.
Hemorrhage
hemorrhage
Postoperative
1/73
L alveolar
T2N
2182
R squamous
T3N1;
3/52
R mesothelioma
Pericardial
4/59
L squamous
T2N2
2/4
Yes
No
Perioperative
wall
3/6
No
Yes
Hypoxemia/pulmonary
hypertension
window
23/27
Yes
Yes
Cardiac
2/23
No
Yes
Hypoxemia;
1
chest
resection
Mi
compression;
tension;
R mesothelioma
6/65
R squamous
T2NO
24/28
7/74
R squamous
T3N2
6/9
No
No
No
No
CO2 retention;
Pneumonitis;
8/36
R AV malformation
6/6
Yes
Yes
Effusion;
tension
pneumothorax;
None/6
9/73
L adenocarcinoma
3/20
Yes
Yes
Staphylococcal
lobar
T3N2
atrial
aspiration
sepsis;
collapse
ARDS
pneumonitis;
resection
subendocardial
R squamous
11/15
R metastatic
12/62
osteosarcoma
R metastatic
Completion
None/15
. . .
Yes
None/lO
.
.
7/16
.
.
Yes
.
Stump
T1N2
R squamous
6/9
No
MI
dehiscence
Pulmonary
.
emboli
Yes
Hypoxemia;
pulmonary
No
emboli
Hypoxemia;
ARDS;
adenocarcinoma
13/84
hyper-
BP fistulat
5/52
10/80
METS
pulmonary
pneumonitis
14/65
R squamous
Completion;
intra-
4/16
Yes
No
Hvpoxemia;
1/16
Yes
Yes
Stump
sepsis
pericardial
15/64
R metastatic
breast
dehiscence;
sepsis;
pulmonary
hypertension
16/68
R squamous
7/21
Intrapericardial
Yes
Yes
Hemothorax;
reoperation;
hypoxemia;
=
stump
dehiscence
26.
tBP, bronchopleural;
added.
and AV, arteriovenous
ISVC,
cava;
Superior
vena
electrocardiographic
unit after
surgery,
tection
of cardiac
MI,
myocardial
malformation;
infarction;
and
ARDS,
monitoring
in the intensive
care
which
certainly
improved
the dedysrhythmias,
especially
those which
may have been asymptomatic.
patients
who were referred
In addition,
to our institution
the types of
for subse-
quent
pulmonary
resection
had had previous
surgery,
as well
as other
types
of therapy
chemotherapy
and irradiation.
Specifically,
tion
pneumonectomy
was not
though
it did not correlate
with
rhythmia,
METS,
it appeared
uncommon,
the incidence
to be associated
with
thoracic
such as
compleand
alof dysa higher
metastatic
adult
disease;
respiratory
none.
distress
no dysrhythmia
occurred,
postop
day
of death
syndrome.
30-day
mortality
(see Table 3). Our 30-day
mortality
of
II percent
is similar
to that
reported
in the series
by
Keagy
et al.2 Compared
to the recent
Lung
Cancer
Study
Group
analysis
from
analyzing
569 pneumonectomies,
6.2
percent
related
with
was
cardiac
In reviewing
proposed
causes
have included
flammation,
reported,
five
participating
a 30-day
but those
centers
mortality
data were
of
not cor-
dysrhythmia.’#{176}
those
studies
of dysrhythmia
hypoxemia,
preexisting
presented
in Table
after pneumonectomy
vagal
cardiac
CHEST /
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irritation,
disease,
91 / 4 /
4,
atrial inpulmonary
APRIL 1987
493
Table
4-Cardiac
Dysrhythmias
Pneumonectomy*
following
Dysrhythmias
Incidence
No. of
Study
Baily
and
Year
Betts4
Currens
et al6
Massie
and
Valle’
Cerney7
Associated
Dysrhythmia,
Pneumonectomies
1943
of
with
percent
percent
No
30-Day
Mortality,
Mortality,
(cases)
deaths
percent
reported
(cases)
78
10
Unavailable
1943
43
21
23 (3/13)
Unavailable
1947
120
34
33 (3/9)
30 (3/10)
Unavailable
1957
9
29
19
Not
discussed
Unavailable
Unavailable
Mowry
and
Reynolds5
1964
Shields
and
Ujiki’
1968
72
9t
6
Not
discussed
Unavailable
1983
58
28
Not
discussed
12 (11/90)
1987
236
22
25 (13/53)1
11
181:
Keagy
et al’
Krowka
et al
*Includes
tNo
only
atrial
fibrillation
prophylactically
1:Prophylactically
§30-day
(“auricular
fibrillation”),
atrial
flutter,
or supraventricular
tachycardia,
and
ventricular
tachycardias.
digitalized.
digitalized.
mortality.
hypertension,
these
and
studies,
first
the
right
onset
postoperative
cardiac
dilation.
of dysrhythmia
week.
In
most
of
was during
Apparently,
most
the
patients
responded
well
or no medication.
to combinations
of digitalis,
quinidine,
There
appeared
to be an increased
frequency
age and,
with
tion of anesthesia-related
could
not demonstrate
previous
previous
in at least
study also addressed
thoracic
irradiation
disturbances
a relationship
not
significant
a statistically
our data.
pulmonary
In no study
function
bances.
None
one
report,
We
A
the association
between
and the frequency
of
following
pneumonecwas suggested,
it was
nary
fluid
vascular
overload
tone
of the
and,
hence,
lung.
remaining
subclinical
dysrhythmias
fluid
overload
in some
noted.
This needs
cases resulting
in the
further
prospective
study.
The
relationship
of intrapericardial
dissection
cardiac
has not
dysrhythmia
following
pulmonary
been
addressed
in the literature.
tionship
between
pericardial
disease
of intrapericardial
dissection
as a cause
may not be comparable.
This finding
studies
needs
additional
confirmation.
Finally,
as previously
documented,2
of the
addressed
or in
hemodynamic
or increased
interstitial
hypoxemia.
with pulmo-
infiltrates
pneumonectomy
edema
after
is intriguing.
pneumonectomy
has recently
been
discussed
by Zeldin
et al,’2 who
reported
the findings
in ten patients.
These
investigators indicated
that this phenomenon
usually
occurs
within
48 hours
after
relatively
hemodynamically
surgery
and can
stable patient.
appear
to be right pneumonectomy
administration
of fluid in an amount
capillary
wedge
occur
in a
Risk factors
and interoperative
greater
than 2,000
pressures
are not nec-
documented,’4
we
but
could
find
no relationship
between
cardiac
rhythm
disturbances
following
pneumonectomy
and preoperative
pulmonary function.
This finding
was not unexpected
and
reinforces
on the
been
and dysrhythmia
the mechanism
for dysrhythmia
study
has
and
resection
The rela-
could hypoxemia
or preoperative
be related
to the rhythm
distur-
chest
x-ray film after
The entity of pulmonary
Pulmonary
precapillary
in acute
patients
in that
of dysrhythmia,
especially
acute
association
of cardiac
dysrhythmia
edema
result
in nonsurgical
finding
consequences
(specifically,
hypotension)
in terms
of
the effect ofdysrhythmia.
Our data did not suggest
that
hypoxemia
is a major contributing
factor to the development
The
or unaltered
Based
on our chest roentgenographic
results,
it would
appear
that certainly
this entity
is more common
than
realized
and may indeed
be responsible
for an acute
a ques-
cause for dysrhythmia.3
an age-related
association.
cardiac
rhythm
tomy.#{176}Although
ml.
nodal
11(26/236)
the
tion
tests
are
the
postoperative
fact
not
that
preoperative
pulmonary
func-
useful
parameters
on which
to base
clinical
course
with
reference
to
cardiac
The
and hemodynamic
function.2’5
implications
of this study focus on the increased
mortality
which
occurred
in patients
that had nonventricular
tachycardias
after pneumonectomy.
The
role of digitalis
tic medications
or other rhythm-stabilizing
prophylacis unclear.
Whether
or not prophylaxis
would
result
in fewer
mortality
and morbidity
in the
literature.
dysrhythmias
has not
Our
been
retrospective
and subsequent
well addressed
study,
although
essarily
elevated
in these individuals.
In fact, pulmonary arterial
pressures
may be falsely low following
documenting
rhythmias,
pneumonectomy
medications
will favorably
affect
morbidity
and mortality.
Future
studies
should
address
the hypothesis
that cardiac
dysrhythmias
after
pneumonectomy
are,
creased
output,
based
to balloon
occlusion
causing
in-
right ventricular
afterload,
reduced
cardiac
and decreased
left atrial pressure.
‘
It appears,
on other
studies,14
that pulmonary
capillary
hydrostatic
494
due
pressure
can be raised
in the setting
of low
in
part,
correlate
the effects
of postoperative
does not imply
that prophylactic
volume-induced
problems
well
hemodynamic
to standard
Cardiac
Oysrhythmia
following
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21558/ on 05/10/2017
which
Pneumonectomy
tachydyscardiac
may
not
monitoring
(Krowka
eta!)
techniques.
Finally,
medications
the
introduction
calcium-channel
(ie,
noninvasive
amiodarone),
of newer
blockers
techniques
cardiac
plicating
cardiac
and
6 Currens
Dop-
(ie,
a potential
pulmonary
importance.
This
type
resection
maybe
of consideration,
nary
surgery
White
thoracic
7 Cerney
CI.
Massie
E,
9 Shields
Valle
TW,
rhythmias
lung.
Ann
Intern
Med
1964;
Cardiac
1943;
Cardiac
Intern
arrhythmias
complicating
1947;
total
26:231-39
Digitalization
pulmonary
complicating
34:105-10
arrhythmias
Med
fol-
229:360-64
arrhythmias
1957;
Surg
Ann
CT.
ED.
Med
of cardiac
AR.
Ujiki
J
N Engi
for
surgery.
prevention
Surg
of
Gynecol
ar-
Obstet
126:743-46
10 Ginsburg
RJ, Hill LD,
J, et
lauras
resection.
Churchill
J Thorac
following
1968;
for pulmo-
of the
prophylaxis
surgery.
pneumonectomy.
medicasurrounding
PD,
surgery.
The
pulmonary
8
of clinical
in conjunction
with a prospective
trial of rhythm-stabilizing
tions,
should
help remove
the mystique
preoperative
digitalization
in the candidate
JH,
lowing
pler echocardiography
and exercise
stress
testing),
and
a combined
cardiopulmonary
approach
to the patient
with
resectional
61:688-95
resections
al.
Eagan
Modern
in lung
RI’, Thomas
thirty
day
J Thorac
cancer.
P. Mountain
operative
CF.
mortality
Cardiovase
Des-
for surgical
Surg
1983;
86:
654-58
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CHEST / 91 / 4 /
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APRIL,
1987
495