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J Thorac Cardiovasc Surg 2008;135:205-206
© 2008 The American Association for Thoracic Surgery
Brief Communication |
a Department of Medicine, Division of Pulmonary and Critical Care Medicine, Temple University School of Medicine, Philadelphia, Pa
c Department of Anesthesiology, Temple University School of Medicine, Philadelphia, Pa
d Department of Surgery, Division of Cardiac and Thoracic Surgery, Temple University School of Medicine, Philadelphia, Pa
b Temple University School of Medicine, Philadelphia, Pa.
Received for publication July 25, 2007; accepted for publication August 15, 2007. * Address for reprints: Nathaniel Marchetti, DO, Division of Pulmonary and Critical Care Medicine, Temple University School of Medicine, 745 Parkinson Pavilion, 3401 North Broad St, Philadelphia Pa 19140. (Email: nathaniel.marchetti{at}tuhs.temple.edu).
Although bullectomy has been shown to decrease dyspnea, work of breathing, residual volume, and total lung capacity and improve respiratory muscle function, its effect on cardiovascular performance is relatively unknown.1-3
Herein, we describe the immediate and long-term effects of bullectomy on cardiac function.
A 42-year-old actively smoking man with a history of chronic obstructive pulmonary disease and intractable dyspnea was referred for bullectomy. Physical examination revealed tachypnea without evidence of jugular venous distension or hepatojugular reflex. The cardiac examination was unremarkable, except for an inferomedially displaced point of maximal impulse. His chest was hyperinflated, with decreased breath sounds in the right hemithorax.
While getting onto the computed tomographic scan table, the patient experienced severe acute respiratory distress and nearly had a respiratory arrest. The patient was transferred to the emergency department, stabilized, and admitted to complete the preoperative evaluation. A chest radiogram (Figure E1, A) displayed a massive right bulla with tension, inverting the right diaphragm, compressing residual right lung tissue, and displacing the heart leftward. The results of pulmonary function testing, cardiopulmonary exercise testing, and echocardiography are displayed in Tables E1 and E2.
The patient was considered at high risk for respiratory failure without surgical intervention and underwent bullectomy after optimization of respiratory medications.
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Effect of bullectomy on cardiac and respiratory physiology
Immediately after bullectomy and reinflation of the right lung, there was a dramatic improvement in cardiac output, cardiac index, and stroke volume. Specifically, stroke volume and cardiac index more than doubled (Table 1). Additionally, there was a decrease in total pulmonary resistance (TPR) and systemic vascular resistance. Pulmonary vascular resistance could not be calculated because the pulmonary artery catheter could not be maintained in the wedge position. Because a preoperative transthoracic echocardiogram provided suboptimal views of cardiac structure, transesophageal echocardiographic studies were performed in the operating room before and after bullectomy. Immediately after bullectomy, the right ventricular function and visualization of cardiac structures improved (Table E2). Pulmonary function testing and cardiopulmonary exercise testing was repeated 9 months after bullectomy (Table E1). The forced expiratory volume in 1 second improved 122%, whereas the residual volume decreased by 40%. After bullectomy, exercise time increased by 87%, and work tolerance increased by 143%. Preoperatively, the O2 pulse (a noninvasive marker for cardiac output) calculated by dividing the oxygen uptake by the heart rate and multiplying by 1000, reached an early plateau, but 9 months after surgical intervention, the oxygen pulse did not plateau during exercise (Figure 1). The chest radiographic analysis 6 months postoperatively (Figure E1, B) exhibited a reinflated right lung with return of cardiac structures to the midline position.
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Our case exemplifies how removal of a massive bulla improves cardiovascular performance in addition to its established beneficial effects on respiratory mechanics. After bullectomy, the patient had significant improvements in exercise time, cardiac output, cardiac index, stroke volume, TPR, systemic vascular resistance, and right ventricular function.
Bullectomy should improve TPR by increasing the pulmonary vascular bed through recruitment of viable pulmonary vessels that had been compressed by the presence of a giant bulla. Our data support this by showing an immediate improvement in right ventricular function, resulting in increased cardiac output accompanied by a reduction in TPR. Follow-up pulmonary function testing showed an improved diffusion capacity, suggesting an increase in pulmonary vascular bed area after bullectomy. Resection of emphysematous lung tissue has been shown to have favorable effects on left ventricular dimensions and cardiac output,4 and in our case the return of cardiac structures to a normal geometry and anatomic position contributed to the immediate improvement in cardiac function because of improved venous return.
To our knowledge, this is the first detailed report of the acute and chronic effect of bullectomy on cardiopulmonary physiology. These improvements are likely caused by improved venous return, recruitment of viable pulmonary vasculature (thus decreasing TPR), and improved geometry of the heart. When evaluating a patient for bullectomy, its potential for improving both cardiac and pulmonary function should be considered and factored into the decision as to whether and when to surgically intervene.
References
This article has been cited by other articles:
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  E. Pompeo, F. Tacconi, L. Frasca, and T. C. Mineo Awake thoracoscopic bullaplasty Eur J Cardiothorac Surg, June 1, 2011; 39(6): 1012 - 1017. [Abstract] [Full Text] [PDF]
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