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Eur J Cardiothorac Surg 1999;15:585-591
© 1999 Elsevier Science NL
a Division of Thoracic Surgery, Department of Surgery, Department of Internal Medicine, University Hospital, Zürich, Switzerland
b Pulmonary Division, Department of Internal Medicine, University Hospital, Zürich, Switzerland
c Division of Cardiology, Department of Internal Medicine, University Hospital, Zürich, Switzerland
Received 22 September 1998; received in revised form 16 February 1999; accepted 2 March 1999.
Corresponding author. Tel.: +41-1-255-8802; fax: +41-1-255-8805
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Abstract |
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 Top Abstract 1. Introduction
2. Patients and methods...3. Results4. Discussion
Appendix A. Conference...References |
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Key Words: Lung volume reduction surgery • Cardiac disease • Outcome
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1. Introduction |
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TopAbstract1. Introduction
2. Patients and methods...3. Results4. Discussion
Appendix A. Conference...References |
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In this study we retrospectively evaluated the perioperative complications and functional outcome of these 12 patients which were operated in combination with cardiac interventions (PTCA, coronary stenting, CABG, valve replacement (VR)).
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2. Patients and methods |
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TopAbstract1. Introduction
2. Patients and methods...3. Results4. Discussion
Appendix A. Conference...References |
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In addition, three patients with valvular heart disease and severe emphysema, which were considered inoperable due to their extremely limited pulmonary function, underwent valve replacement in combination with LVRS.
2.1. Patients with CAD
Coronary angiography revealed relevant coronary artery disease in nine patients (one female) with a median age of 66 (56–74) years. Three patients had three-vessel disease, four two-vessel-, and two one-vessel disease. One patient with predominantly unilateral diffuse emphysema underwent unilateral lung volume reduction surgery on the right side following coronary artery bypass grafting (x5) in one session. LVRS was performed through the median sternotomy when the patient was still on bypass using ELC45 staplers (Ethicon, Endo-Surgery, Switzerland) buttressed with bovine pericardium (Peri-Strips DryTM, Biovascular INC, Saint Paul MN). In the second patient LVRS was performed bilaterally by video-endoscopic approach six months after CABG (x4). The other patients underwent PTCA (n=7) and/or placement of a stent (n=4) 4–6 weeks prior to bilateral thoracoscopic LVRS. The patients received Ticlid® (Ticlopidin) 2x250 mg/day and Aspirin 100 mg/day for 4 weeks. The medication was stopped 1 week prior to LVRS.
2.2. Patients with valve disease
All three patients (67–70 years) who underwent LVRS in combination with replacement of the mitral or aortic valve were initially not accepted for a cardiac surgical intervention because of severe COPD with emphysema. The rationale for the combined treatment was to improve pulmonary function postoperatively with the aim to faciliate weaning from the respirator [6]. Bilateral LVRS was performed in one patient immediately after aortic valve replacement through the median sternotomy. In the other two patients LVRS was postponed because of intraoperative complications during the cardiac intervention.
2.3. Surgical technique
Our standard procedure is lung volume reduction surgery (LVRS) performed bilaterally by video-assisted thoracoscopy (VAT), as described previously (2]. Briefly, three 11.5 mm trocars are placed in the 7th or 8th ICS and a 5.5-mm trocar in the 4th ICS. A 10-mm, 25° angled thoracoscope is used. The resection is aimed at the most destroyed tissues previously identified by CT scans and perfusion scintigraphy.
In cases with upper lobe predominance or a diffuse type, 20–30% of the lung volume is resected from the apical upper lobe in the shape of an inverted ‘hockey stick’. In the other cases the resection is aimed at the most destroyed areas. Two chest tubes on each side are connected to a chest tube drainage system with Heimlich valves or suction of 10 to 20 cm H2O.
In the patients who underwent CABG or valve replacement combined with LVRS in one operation, LVRS was performed through the median sternotomy when the patient was still on bypass. The resection was performed using an Endolinear cutter (ELC45 Ethicon, Endo-Surgery, Switzerland) buttressed with bovine pericardium (Peri-Strips DryTM, Biovascular INC, Saint Paul MN).
2.4. Functional assessment
Lung volumes were measured in a standardized manner (Sensor Medics 66200 Autobox; Yorba Linda, CA) [7]. Results were expressed as the best values after inhalation of two puffs of salbutamol. Diffusing capacity for carbon monoxide was measured by the single breath technique (66200/Sensor Medics). Reference values were according to the European community for steel and coal [8].
Exercise capacity was assessed by the 12-min walking test. The patients walked along the same hospital hallway without oxygen supplementation encouraged by a technician [9].
2.5. Statistical analysis
Data analysis was performed by analysis of variance (ANOVA) with planned comparison using a commercially available program (STATISTICA for Windows, Version 4.5).
Continuous data are given as mean ± standard error of the mean (SEM). Demographic parameters are given as median and range. P-Values less than 0.05 were considered significant.
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3. Results |
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TopAbstract1. Introduction
2. Patients and methods...3. Results4. Discussion
Appendix A. Conference...References |
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3.2.1. Patient 1
In a 73-year-old female with known COPD and emphysema (FEV1 0.8 l, 42% predicted, TLC 5.45 l, 110% predicted, RV 3.5L, 165% predicted) a severe aortic valve stenosis (mean gradient 85 mmHg) was diagnosed. She suffered from severe dyspnea during normal daily activity and severe orthopnea at night.
Combined aortic valve replacement and bilateral lung volume reduction surgery was performed in the same session via median sternotomy. Postoperatively, severe pulmonary arterial hypertension developed and was treated with NO inhalation. The patient was weaned from the respirator and extubated on the 12th postoperative day. Antibiotic therapy was required for a unilateral pneumonia and the patient was leaving the hospital on day 28 postoperatively.
In the 3 months follow-up examination bronchial obstruction had decreased as well as pulmonary hyperinflation (FEV1 0.88L, 44% predicted, TLC 4.72 l, 95% predicted, RV 2.7 l, 128% predicted).
3.2.2. Patient 2
A 67-year-old female with biventricular cardiac insufficiency (NYHA 3-4), mitral valve stenosis and a mild aortic valve insufficiency was refused in 1994 for mitral valve replacement because of severe COPD (FEV1 0.84L, 36% predicted, RV/TLC ratio 0.75, diffusing capacity for carbon monoxide (DLCO) 39% predicted). The patient was a heavy smoker for 25 years and was on long-term oxygen therapy since the beginning of 1996. She suffered from severe dyspnoea (Medial research council (MRC) dyspnea score: 4), and was very limited in her exercise capacity (12-min walking distance 540 m).
A combined mitral valve replacement and lung volume reduction surgery in the same session was planned. After valve replacement, however, a type A dissection occured. LVRS was postponed and performed 3 days later which faciliated successful weaning fom the respirator.
The late postoperative course was further complicated by urosepsis and the patient was discharged from the hospital on day 37 postoperatively.
Three months after the operation, dyspnea and exercise capacity were markedly improved (MRC: 1; 12-min walking distance 675 m), and lung function showed less obstruction (FEV1 1.47 l, 67% predicted) and overinflation (RV/TLC 0.54). DLCO revealed a slight improvement to 49% predicted. Long-term oxygen therapy was no longer necessary. One year after the operation the patient was in good general condition with FEV1 of 53% predicted, RV/TLC ratio 0.50, and a 12-min walking distance of 808 m.
3.2.3. Patient 3
A 68-year-old previous heavy smoker suffered from COPD with alpha-1-antitrypsin deficiency and severe bullous emphysema. Furthermore a combined aortic valve disorder with dominant stenosis (mean gradient 35 mmHg) was known. Since pulmonary emboli were suspected, the patient received coumarine since year one. FEV1 was 1.3 l (47% pred.).
After several hospitalisations for pulmonary decompensation a simultanous valve replacement and LVRS was planned. Due to accidental perforation of the left ventricle during the aortic valve replacement, bilateral LVRS was performed by video-assisted thoracoscopies (VATS) 10 days after the cardiac intervention. At this time point a pulmonary infection with a multiresistant Pseudomonas was diagnosed.
After a prolonged weaning period and slow improvement of the lung function the patient developed severe pneumonia. In the later postoperative course infectious parameters increased. On the 15th postoperative day the patient died from multi-organ failure following intestinal infarction.
3.2.4. Morbidity and mortality
One patient in the group with CAD died after development of pulmonary edema on day 2 postoperatively and one patient after valve replacement and LVRS died because of intestinal infarction on day 14 postoperatively (Table 2).
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3.2.5. Drainage time and hospital stay
In the 12 patients with combined intervention median drainage time was 11.5 days (range 5–30 days).
The median hospital stay was 15 days (range 10–33 days). In contrast, the two surviving patients after valve replacement were hospitalised longer, for 28 and 37 days respectively.
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4. Discussion |
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TopAbstract1. Introduction
2. Patients and methods...3. Results4. Discussion
Appendix A. Conference...References |
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At the University of Zurich the LVRS program has been started in early 1994. All patients were included in a prospective study. Nearly 300 patients have been evaluated and 124 underwent surgery for emphysema. LVRS at our institution is mainly performed bilateral in one session by a video-thoracoscopic approach.
Smoking is the main risk factor for emphysema as well as for coronary artery disease. Therefore, in these patients additional risk factors as CAD have to be excluded. Exercise testing, however, in COPD patients is often not possible due to severe pulmonary limitation.
In a previous prospective study we could demonstrate that clinically silent, but relevant CAD is a frequent finding in emphysema patients, otherwise qualifying for LVRS [3]. We found that in 15% of LVRS candidates at least one relevant coronary artery stenosis (>70% or a 50% stenosis of the left main coronary artery) is present. After treatment of CAD with PTCA, stent, or CABG, LVRS can be performed safely with a low mortality and morbidity similar to the group of patients without CAD.
When LVRS was performed on a patient while on cardiopulmonary bypass, buttressing with bovine pericardial strips was always used with the aim to prevent bleeding in the fragile lung tissue of the emphysematous lung. The improvement in pulmonary function and exercise performance was identical in the nine CAD patients as compared to patients without CAD. These data suggest that a combination of both interventions is feasible. However, in our experience it seems to be favourable to select the patients carefully and to operate preferentially on patients which are more likely to improve functionally after LVRS (e.g. heterogenous emphysema with good target areas) [10].
The rationale for LVRS in patients with valvular heart disease was different [6]. The combined procedure was only performed when the patient was severely limited preoperatively and unable to maintain even everyday acivities after failure of all conservative treatment modalities. Basically, the patients were considered inoperable for valve replacement due to their respiratory insufficiency resulting from severe COPD with emphysema. LVRS was performed with the aim to improve pulmonary function to faciliate postoperative weaning from the respirator. The intraoperative course of two of the described patients during the cardiac intervention was complicated and LVRS was postponed and performed 3 and 10 days later under more stable conditions. Two patients after valve replacement and LVRS showed equal or even improved pulmonary function and exercise performance 3–6 months postoperatively (Fig. 2).
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Postoperative pulmonary improvement in patients who underwent CABG or valve replacement are even more impressive since it has been demonstrated in previous studies that in patients with normal preoperative respiratory function who undergo cardiac surgery (CABG or valve replacement) FEV1 and FVC decrease postoperatively by at least 10% over several months [12].
Our experience with surgical treatment for empysema and cardiac valve disorder demonstrates that combined interventions can be performed successfully in selected patients. The morbidity and mortality are acceptable. However, this surgical concept can only be recommended for centers with a large experience in postoperative management of patients with severe emphysema.
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Footnotes |
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Appendix A. Conference discussion |
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TopAbstract1. Introduction
2. Patients and methods...3. Results4. Discussion
Appendix A. Conference...References |
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Dr Schmid: I think this is risk stratifying. In the valve patient, it was always planned to perform LVRS through the median sternotomy in the same session at the end of the procedure when the patient was still on bypass. We used buttressing of the staple line in all cases to prevent parenchymal haemorrhage, and we did not have any bleeding problems. On two occasions, during the cardiac intervention severe intraoperative complications occurred, which prolonged bypass time, and we had to delay the lung volume reduction procedure. One patient we tried to wean from the respirator, but it was impossible. Lung volume reduction surgery was performed and 10 days later we could extubate the patient. This case was published in the Journal of Thoracic and Cardiovascular Surgery in 1998.
Dr F. Venuta (Rome, Italy): I did not understand which procedures you did first in the series of patients that you treated at the same time with cardiac procedure and lung volume reduction. I mean, did you do the lung volume reduction before putting the patient on bypass, or after?
Dr Schimd: After the cardiac operation, but still on bypass.
Dr Venuta: So you reversed heparin and then you did the lung volume reduction?
Dr Schmid: No, we performed LVRS. When the patient was, as I just mentioned, still on bypass.
Dr T. Dosios (Athens, Greece): I understood that all your patients had coronary arteriogram done before the operation. Is it correct?
Dr Schmid: In the very initial experience of lung volume reduction surgery, we performed it in all patients. Evaluating our data, we found that it is only indicated when you have clinical suspicion, or certain risk factors, except smoking of course. In general, we do now perform LVRS without coronary angiography.
Dr P. Baptista (Carnaxide, Portugal): From what I understood in the beginning, you did coronary angiograms in all patients proposed to lung reduction. And then you said you only did it when there was suspicion of cardiac pathology. Why not do just stress efforts in every patient, which is something we can do very easily?
Dr Schmid: The emphysema patients usually can not perform ergometry because of their pulmonary limitation. Therefore, if there is any clinical suspicion for coronary heart disease we liberally perform angiography.
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References |
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TopAbstract1. Introduction
2. Patients and methods...3. Results4. Discussion
Appendix A. Conference...References |
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