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J Thorac Cardiovasc Surg 1998;115:236-237
© 1998 Mosby, Inc.
BRIEF COMMUNICATIONS |
Zürich, Switzerland
From the Departments of Surgery,a Anesthesiology,band Internal Medicine,c University Hospital, Zürich,Switzerland.
Received for publication April 29, 1997 Accepted for publication June 6, 1997. Address for reprints: Walter Weder, MD, Department of Surgery,University Hospital, Rämistrasse 100, CH 8091 Zürich, Switzerland.
Lung volume reduction surgery (LVRS) may be indicated after cardiacoperations to improve pulmonary mechanics in patients with severe emphysema whoare receiving mechanical ventilation. This intervention facilitates successfulweaning.
History. A 57-year-old woman who formerlysmoked cigarettes had severe mitral stenosis and pulmonary emphysema and wasevaluated for mitral valve replacement. She had been receiving long-term homeoxygen therapy for 7 months. The patient had been repeatedly hospitalized duringthe previous year because of exacerbation of chronic obstructive pulmonarydisease. At a previous anesthesiologic evaluation, the patient had beenconsidered to be ineligible for operation because a reduction of respiratoryfunction of at least 30% is to be expected in the early postoperativephase after mitral valve replacement.
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Preoperative cardiac findings.Echocardiograpy documented severe mitral stenosis (mitral valve area 0.8 cm2)with an almost immobile mitral valve. The left ventricular ejection fraction wasnormal (64%). Both atria were dilated.
Coronary angiography revealed a normal coronary circulation.Catheterization of the left side of the heart demonstrated slight mitral andaortic insufficiency (regurgitation 20%). The diastolic pressure gradientacross the mitral valve was 13 mm Hg.
Preoperative pulmonary findings. Thepatient was extremely limited in her everyday activities. The data on herpreoperative pulmonary function are summarized in Table I.Blood gas analysis while she was receiving medical therapy showed an oxygentension of 54 mm Hg, a carbon dioxide tension of 44.4 mm Hg, and an oxygensaturation of 89% without supplemental oxygen. Computed tomographic scanof the chest revealed moderately heterogenous bilateral distribution of theemphysema, with predominance in the apical segments of the lower lobes and theright upper lobe.
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Eight hours after the operation, an unstable early postoperative coursenecessitated reoperation for pericardial tamponade. Bilateral pneumothoraxdeveloped on the first postoperative day, and extubation was impossible. On theleft side, a severe air leak persisted. Mechanical ventilation with an inspiredoxygen fraction of 1.0 was needed. Bilateral LVRS was performed on the thirdpostoperative day. The left side was operated on through a thoracotomy to ensurethe inclusion of the air leak in the area of resection. The right side wasoperated by means of video-assisted thoracoscopy. The apical segments of thelower lobes on both sides and the most destroyed parts of the upper lobe on theright side (anterior and apical segment) were resected with nonbuttressedendoscopic staples (TLC 45; Ethicon Endo-Surgery, Cincinnati, Ohio).
Immediately after LVRS, ventilation became more effective. The tidalvolume increased by 40%, and the inspired oxygen fraction could bereduced from 1.0 to 0.65.
The postoperative course was complicated by urinary tract infection withEscherichia coli and by pneumonia caused byPseudomonas aeruginosa. Tracheotomy wasperformed on day 5 after LVRS. Subsequently, the patient could be weaned fromthe ventilator. The tracheal cannula was removed 18 days after the LVRS.
During the remainder of the patient's hospitalization, oxygensupplementation was reduced to intermittent application of 0.5 L/min. Pulmonaryfunction at 3 months revealed an impressive increase of forced expiratory volumein 1 second and a marked decrease of the ratio of residual volume to total lungcapacity (Table I). The patient was able to performeveryday activities without oxygen supplementation.
Comment. LVRS has been reintroduced intoclinical practice in recent years as a treatment for severe pulmonary emphysema. 2 LVRS improves respiratory mechanicsby reduction of the hyperextension of the emphysematous chest and results in amarked improvement of respiratory function. 3
Argenziano and associates 4reported extended indications for LVRS. Our group demonstrated that LVRSimproves pulmonary function maximally in patients with a heterogenous pattern ofemphysema, but exceptional indications for LVRS must be evaluated. 5 Commonly, the procedure is performedon an elective basis under stable conditions. To our knowledge, this is one ofthe first reports of LVRS in a patient dependent on mechanical ventilation. Ourobservations show that LVRS improved the respiratory condition of the patientimmediately and made subsequent extubation possible 18 days later.
Previous studies have demonstrated reduced pulmonary function as long as6 months after mitral valve replacement. 1In contrast, we noted persistent respiratory improvement at 3 months after theoperation. Before and after the operation, the patient did not show signs ofleft ventricular insufficiency; therefore, the improvement in pulmonary functionseems the result solely of the reduction in lung volume.
We conclude that LVRS may be performed successfully in selected patientswith severe pulmonary emphysema who are dependent on mechanical ventilation, andthat it facilitates successful weaning. In addition, the favorable outcome inthis case may indicate that the pulmonary risk of patients for whom severeemphysema is the only contraindication for cardiac surgery could be reduced whenpostoperative respiratory function is improved by simultaneously performed LVRS.
References
This article has been cited by other articles:
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  I. Baeyens, M. F. Maguire, C. D. Sheldon, and R. G. Berrisford Lung volume reduction surgery in a ventilator-dependent patient Interact CardioVasc Thorac Surg, June 1, 2004; 3(2): 237 - 239. [Abstract] [Full Text] [PDF]
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 Y. Okita, M. Ando, K. Minatoya, O. Tagusari, S. Kitamura, N. Nakajjma, and S. Takamoto Early and long-term results of surgery for aneurysms of the thoracic aorta in septuagenarians and octogenarians Eur J Cardiothorac Surg, September 1, 1999; 16(3): 317 - 323. [Abstract] [Full Text] [PDF]
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