Eur J Cardiothorac Surg 2008;33:268-271. doi:10.1016/j.ejcts.2007.10.020
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Haemodynamic complications after pneumonectomy: atrial inflow obstruction and reopening of the foramen ovale
Clemens Aignera,
György Langa,
Shahrokh Taghavia,
Mir Ali Reza-Hodaa,
Gabriel Martaa,
Helmut Baumgartnerb,
Walter Klepetkoa,*
a Department of Cardio-Thoracic Surgery, Medical University of Vienna, Waehringer Guertel 18 – 20, 1090 Vienna, Austria
b Department of Cardiology, Medical University of Vienna, Austria
Received 2 June 2007;
received in revised form 6 October 2007;
accepted 29 October 2007.
* Corresponding author. Tel.: +43 1 40400 5644; fax: +43 1 40400 5642. (Email: walter.klepetko{at}meduniwien.ac.at).
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Abstract
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Background: Haemodynamic impairments after pneumonectomy are rare complications and present in different forms. Due to a low awareness of these potential complications their diagnosis is difficult and often established late. The most important forms are: firstly reopening of a previously closed foramen ovale (PFO) caused by a combination of changed anatomic position of the left atrium and elevated pulmonary artery pressure leading to a significant right-left shunt; secondly diaphragmatic relaxation can lead to a dislocation of the liver into the right hemithorax, compressing the right atrium with subsequent inflow obstruction. Methods: We retrospectively analysed our patient cohort from 1997 to 2006 for occurrence of haemodynamic complications requiring surgical intervention after pneumonectomy. Results: Five hundred and forty-six pneumonectomies were performed in our centre during the observation period. Five patients (1 female, 4 male, age 59 ± 9 years) with haemodynamic complications were identified. Two of those patients were referred with haemodynamic complications after pneumonectomy was performed in a peripheral centre. All patients had undergone right pneumonectomy for NSCLC (n
= 4) or atypical carcinoid (n
= 1). Two patients were readmitted 3 months and 2 years postoperatively due to increasing platypnoea and orthodeoxia. After closure of the reopened foramen ovale, which was found as the underlying pathological mechanism, respiratory symptoms were resolved. One patient required reintubation 2 h postoperatively; after surgical closure of a PFO the respiratory situation significantly improved. One patient was readmitted due to right atrial inflow obstruction 17 months after right pneumonectomy. Underlying cause was a severe diaphragmatic relaxation with compression of the atrium by the liver. After diaphragmatic plication all symptoms resolved. However 1 year thereafter reoperation for recurrence of diaphragmatic elevation was required. One patient was readmitted 3 months after pneumonectomy and partial atrial resection for cyanosis and dyspnoea. Diagnostics revealed a PFO and a massive raise of the right diaphragm with compression of the right atrium. After surgical correction of the contorted foramen ovale and diaphragmatic plication, symptoms vanished. Conclusion: Haemodynamic alterations due to a reopened foramen ovale or right atrial inflow obstruction are rare, however they are severe complications after pneumonectomy. They occur at variable points in time after pneumonectomy. Diagnostic efforts are often made at a late stage due to a low awareness of the problem. Closure of the PFO either surgical or interventional and/or plication of the elevated diaphragm are mandatory. In our experience these complications occur only after right pneumonectomy.
Key Words: Pneumonectomy • Haemodynamic complication • Inflow obstruction • Reopened foramen ovale • Complication management
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1. Introduction
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Haemodynamic impairments after pneumonectomy are rare complications. Two main forms of haemodynamic alterations are described. Changes in the anatomical situation of the left atrium alone or in combination with a postoperatively elevated pulmonary artery pressure can lead to a significant right-left shunt via a previously closed foramen ovale (PFO). Diaphragmatic relaxation can lead to a dislocation of the liver into the right hemithorax, thereby compressing the right atrium with subsequent inflow obstruction. Literature on this topic consists mainly of reports on single cases. The first reports on right-left shunt after pneumonectomy date back to the 1950s [1,2]. Symptoms include platypnoea and orthodeoxia with deterioration in the upright position [3]. Diagnosis of these complications is difficult and often established at a late stage due to a low awareness of these potential problems. This paper summarises our experience with this type of complication after pneumonectomy.
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2. Methods
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We retrospectively analysed all consecutive patients undergoing pneumonectomy from 1997 to 2006 at our department. Patients were screened for the occurrence of haemodynamic complications requiring surgery or invasive interventions. Intra- or extrapericardial pneumonectomy depending on tumour spread was performed in standard fashion with routine coverage of the bronchial stump. Additionally, two patients were referred for occurrence of haemodynamic complications after pneumonectomy at an external centre and were included in the study. Follow-up was performed at our department or at the referring physician.
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3. Results
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Out of 546 pneumonectomies during the observation period, 5 patients (1 female, 4 male; mean age 59 ± 9 years) with haemodynamic complications were identified. All of them had a history of right pneumonectomy due to non-small cell lung cancer (NSCLC) (n
= 4) or atypical carcinoid (n
= 1).
Patient 1: A 64-year-old male patient was readmitted 2 years after intrapericardial right pneumonectomy for treatment of a centrally located adenocarcinoma G2T2N0M0. The initial postoperative course was uneventful. However 2 years thereafter he developed increasing exertion dyspnoea. He underwent echocardiography, which revealed a reopened foramen ovale with a significant right-left shunt. The PFO was surgically corrected. A median sternotomy was chosen as the approach to avoid re-entering the postpneumonectomy space. The PFO was closed in a standard fashion on cardiopulmonary bypass with bicaval cannulation. A direct closure with a non-absorbable running suture was possible and no patch required. Postoperative course was prolonged due to a temporary renal failure. Echocardiography showed regular findings at all examinations. Four days of ICU stay were required to treat the renal failure and 2 weeks thereafter the patient was discharged without residual symptoms. He remained symptom less and free of tumour recurrence during the entire follow-up of 9 years.
Patient 2: A 49-year-old male patient was readmitted 3 months after right pneumonectomy for a central adenocarcinoma G2T2N0M0 with preoperative induction chemotherapy. The main symptom was a typical platypnoea and orthodeoxia syndrome with hypoxia especially in the upright position. Reopening of the foramen ovale was identified as the underlying pathological mechanism. After transcatheter closure with an Amplatzer occluder respiratory symptoms were resolved. The patient remained free of symptoms during a follow-up of 2 years.
Patient 3: A 69-year-old male patient after right sleeve pneumonectomy was extubated on the operating table. However reintubation was required for 2 h postoperative with inability to maintain adequate saturation. Sleeve pneumonectomy was performed for a squamous cell carcinoma G2T4N0M0 after induction chemotherapy. Postoperative transoesophageal echocardiography showed a massive right-left shunt via a reopened foramen ovale. On the first postoperative day, the patient was re-operated via the initial right anterolateral thoracotomy. The patient was taken on cardiopulmonary bypass with bicaval cannulation and the defect was closed with a pericardial patch. Due to the size of the ASD a tension-free direct closure was not possible. Saturation thereafter significantly improved. In the further course the patient developed a bacterial and mycotic pneumonia in the residual lung with increasing ventilation effort and despite maximal intensive therapy the patient died 33 days postoperatively.
Patient 4: A 53-year-old female patient was readmitted 17 months after right intra-pericardial pneumonectomy for a centrally located squamous cell carcinoma G2T1N1M0. Haemodynamic symptoms were caused by a left atrial inflow obstruction. A severe diaphragmatic relaxation with compression of the atrium by the liver was found as the underlying cause. The patient underwent re-thoracotomy with mobilisation and plication of the diaphragm. Thereafter all symptoms temporarily resolved. However 1 year later the patient was referred again due to a sudden onset of dyspnoea and haemodynamic symptoms. CT scan showed a recurrent massive diaphragmatic relaxation with significant dislocation of the liver. Echocardiography showed a substantial compression of the right atrium by the left liver lobe. A revision and a new plication of the diaphragm were performed again via a right anterolateral thoracotomy, leading to an immediate relief of symptoms. The patient remained thereafter free of symptoms and tumour recurrence during the 3-year follow-up period after the primary operation.
Patient 5: A 62-year-old patient was readmitted 3 months after pneumonectomy and partial atrial resection at another hospital for an atypical carcinoid of the right lung due to cyanosis and dyspnoea. Patient history showed a prolonged reversible ischaemic neurologic deficit with left hemisyndrome and motoric aphasia 2 weeks prior to admission. Diagnostics, including a right heart catheterisation, revealed a PFO and a massive raise of the right diaphragm with compression of the right atrium (Figs. 1 and 2
). Since a combined repair was planned, a right anterolateral thoracotomy was chosen. Initially the diaphragm was fully mobilised and plicated. Thereafter the patient was taken on cardiopulmonary bypass with bicaval cannulation and the foramen ovale was closed with a running non-absorbable suture. After surgical correction of the contorted foramen ovale and diaphragmatic plication symptoms vanished. The intraoperative situs prior and after correction are shown in Figs. 3 and 4
. The patient remained free of symptoms and tumour recurrence during the 3-year follow-up.
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Fig. 1. CT scan 3 months after pneumonectomy showing a massive elevation of the right diaphragm with consecutive obstruction of the right atrium and inflow occlusion (frontal plane).
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Fig. 2. CT scan 3 months after pneumonectomy showing a massive elevation of the right diaphragm with consecutive obstruction of the right atrium and inflow occlusion (axial plane).
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4. Discussion
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Haemodynamic complications after pneumonectomy are generally rare conditions, however they are important to be considered in case of clinical deterioration of the patient after pulmonary resection. Rapid or slowly progressive functional deterioration after pneumonectomy needs a thorough diagnostic workup. Underlying causes can be grouped into progression of pre-established diseases such as chronic obstructive pulmonary disease or cardiac diseases, mechanical impairments of airflow due to distortion of the central tracheobronchial tree and mechanical impairments leading to haemodynamic alterations. An asymptomatic PFO is present in approximately 20% of the population. A symptomatic right to left shunt can occur even without elevated right heart pressure after pulmonary resection. It typically evolves after an interval of a few months without relevant symptoms after the operation [4]. The second typical characteristic is the posture dependency with worsening of dyspnoea and arterial oxygen desaturation in the upright position and relief by recumbency, the so-called platypnoea-orthodeoxia syndrome. Furthermore, a volume dependency of the shunt can be observed with a higher shunt volume in a dehydrated state [5]. Only a few reports deal with this topic. From 1956 to 2004 only 46 patients were reported worldwide [6]. The largest series thereafter was published by a French multicentre group covering 36 cases of PFO after pneumonectomy that were treated by transcatheter closure with various systems [7]. However, interventional closure of a reopened foramen ovale after pneumonectomy is difficult due to a distorted anatomy. Almost uniformly this complication occurs after right pneumonectomy. Only exceptional cases after left pneumonectomy or even after right lobectomy are reported [6,8]. Another clinical condition potentially leading to platypnoea-orthodeoxia syndrome is an aneurysm or elongation of the ascending aorta. The symptom less period after pulmonary resection reported in a large review ranges from 1 to 31 months with a mean of 6 months [6]. In our experience one patient developed a massive shunt on the first day after a right sleeve pneumonectomy. Such an early onset of symptoms has not been reported so far and might be explained by a pre-existing moderate elevation of pulmonary artery pressure and postoperatively additional elevation in right heart pressure.
A single report also describes a prophylactic closure of a PFO prior to a forthcoming pneumonectomy to avoid postoperative problems [9].
The second complication potentially leading to haemodynamic impairment after pneumonectomy is a massive relaxation and consecutive elevation of the diaphragm with a dislocation of the liver into the right hemithorax. This complication has been described after diaphragmatic resection [10], however it occurred in our experience even with an intact diaphragm. Diagnosis was made in our patients by CT scan (Figs. 1 and 2) and transthoracic echocardiography. One patient who additionally presented with a shunt via a reopened foramen ovale also underwent right cardiac catheterisation. Diaphragmatic plication is the therapy of choice in these patients and symptoms were resolved in both cases. Resection of the phrenic nerve might potentially contribute towards development of this complication, however in one case it developed even though the phrenic nerve was preserved.
The choice of the surgical approach depends on the underlying pathology and the time period since the initial operation was performed. In case of an elevated diaphragm obviously a right-sided thoracotomy is the appropriate approach. If necessary, the patient can easily be taken on cardiopulmonary bypass and an ASD can be additionally corrected by this approach. Cardiopulmonary bypass can either be installed centrally with bicaval cannulation as described in our patients or can alternatively be installed via a femorofemoral approach.
If an isolated correction of an ASD is required, the choice of the approach will mainly depend on the initial operation. If the initial operation was performed by a right-sided thoracotomy, the same incision can be used again in the early postoperative phase. If the intervention is required in the later postoperative follow-up, a median sternotomy might be more advisable, since postoperative adhesions or re-entering a postpneumonectomy space can be avoided.
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5. Conclusion
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The development of haemodynamic complications after pneumonectomy is rare and occurs mainly after right-sided pneumonectomy. The development of a right-to-left shunt via a PFO usually occurs after a symptom-free interval and is most likely related to intrathoracic anatomical remodelling. Diaphragmatic elevation with consecutive dislocation of the liver also occurred in our experience after a symptom-free interval. CT scan, echocardiography and eventually right cardiac catheterisation are the diagnostic methods of choice. Surgical or interventional treatment has to be performed as soon as the diagnosis is established and leads to relief of symptoms in all cases.
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Footnotes
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\#9734; Presented at the 15th European Conference on General Thoracic Surgery, Leuven, Belgium, June 3–6, 2007.
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References
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- Dlabal PW, Stutts BS, Jenkins DW, Harkleroad LE, Stanford WT. Cyanosis following right pneumonectomy: importance of patent foramen ovale. Chest Mar 1982;81(3):370-372.[CrossRef][Medline]
- Schnabel Jr. TG, Ratto O, Kirby CK, Johnson J, Comroe Jr. JH. Postural cyanosis and angina pectoris following pneumonectomy: relief by closure of an interatrial septal defect. J Thorac Surg Aug 1956;32(2):246-250.[Medline]
- Begin R. Platypnea after pneumonectomy. N Engl J Med Aug 1975;293(7):342-343.[Medline]
- Smeenk FW, Postmus PE. Interatrial right-to-left shunting developing after pulmonary resection in the absence of elevated right-sided heart pressures. Review of the literature. Chest 1993;103:528-531.[CrossRef][Medline]
- Wranne B, Tolagen K. Platypnoea after pneumonectomy caused by a combination of intracardiac right-to-left shunt and hypovolaemia. Relief of symptoms on restitution of blood volume. Scand J Thorac Cardiovasc Surg 1978;12(2):129-131.[Medline]
- Marini C, Miniati M, Ambrosino N, Formichi B, Tonelli L, Di Ricco G, Michelassi C, Giusti S, Spadoni I. Dyspnoea and hypoxaemia after lung surgery: the role of interatrial right-to-left shunt. Eur Respir J 2006;28(1):174-181.[Abstract/Free Full Text]
- Guerin P, Lambert V, Godart F, Legendre A, Petit J, Bourlon F, De Geeter B, Petit A, Monrozier B, Rossignol AM, Jimenez M, Crochet D, Choussat A, Rey C, Losay J. Transcatheter closure of patent foramen ovale in patients with platypnea-orthodeoxia: results of a multicentric French registry. Cardiovasc Intervent Radiol Mar-Apr 2005;28(2):164-168.[CrossRef][Medline]
- LaBresh KA, Pietro DA, Coates EO, Khuri SF, Folland ED, Parisi AF. Platypnea syndrome after left pneumonectomy. Chest May 1981;79(5):605-607.[CrossRef][Medline]
- Yalonetsky S, Nun AB, Shwartz Y, Lorber A. Transcatheter closure of a patent foramen ovale prior to a pneumonectomy to prevent platypnea syndrome. Eur J Cardiothorac Surg 2006;29(4):622-624.[Abstract/Free Full Text]
- Huwer H, Winning J, Isringhaus H, Kalweit G. Post-pleuropneumonectomy herniation of liver mimicking major pulmonary embolism. Asian Cardiovasc Thorac Ann Jun 2006;14(3):e60-e62.[Abstract/Free Full Text]
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Abstract
1. Introduction
