Abstract
Objective: To describe the possible postoperative cardiac
arrhythmias after major lung resection surgery performed for lung malignancies.
Methods: This descriptive study was conducted from January
2007 to October 2009 at the Thoracic Surgery Division of the Royal Medical
Services in Amman-Jordan. Forty-eight patients were included in this study.
Patients with pre existing cardiac diseases were excluded. All the patients
underwent different types of major lung resection surgery for primary and
secondary lung malignancies. Postoperative cardiac arrhythmias after different
types of lung resection surgery were documented and described. Simple
descriptive statistics were used.
Results: The sample included 35 males (72.9%) and 13
females (27.1%). Age ranged between 21 to 82 years (mean 56.6 ± 14.9). Left sided surgery was performed in 21 patients (43.7%),
while right sided resections were performed in 27 patients (56.3%). Lobectomy
was the most commonly performed operation which was carried out in 27 patients
(56.3%), followed by pneumonectomy which was performed in 14 patients (29.2%). Post
operative cardiac arrhythmias occurred among 19 patients (39.6%). Atrial
fibrillation was the most common reported arrhythmia which occurred in 15
patients (31.2%), followed by supra ventricular tachycardia in 2 patients (4.2%),
and 2 patients developed atrial flutter (4.2%). Cardiac arrhythmias were
observed to be more common after lobectomy or pneumonectomy, in old male
patients, and during the first 48 hours post lung resection.
Conclusion: Post major lung
resection cardiac arrhythmias are common. Preoperative evaluation
and postoperative cardiac monitoring are mandatory in these patients even among those
without pre existing cardiac diseases.
Key
words: Arrhythmias, Lung cancer, Lung resection
JRMS
March 2011; 18(1): 10-14
Introduction
According to the 2005 World
Health Organization report, lung cancer is the leading cause of cancer related
deaths in males and the fourth cause of cancer related deaths in females in
Jordan.(1) Surgical
resection is the best therapeutic option, and provides the best chance of
prolonged survival for the early stages nonsmall-cell lung carcinoma.(2,3)
Surgical treatment was defined as a treatment when the patient had any
pulmonary resection for the primary tumor, including pneumonectomy,
bilobectomy, lobectomy, segmentectomy, and wedge resection.(4)
Post-lung resection complications, especially pulmonary and cardiac
complications, are likely to prolong hospitalization and increase the cost of
hospital care, and are associated with an increased risk of mortality.(5)
Arrhythmia, more particularly atrial fibrillation, is by far the most common
cardiac complication after non-cardiac
thoracic surgery, with an incidence ranging from 10% to 20% after lobectomy and
as much as 40% after pneumonectomy.(6) In this study, we report the possible
postoperative cardiac arrhythmias after major lung resection surgery performed
for lung malignancies.
Methods
This descriptive study was conducted during the period from January 2007
through October 2009 at the Thoracic Surgery Division of the Royal Medical
Services in Amman-Jordan. Data were retrieved from the Thoracic Surgery Division
computerized database and from the medical records. Forty-eight patients were
included in this study. All the study patients were diagnosed to have a primary
or a secondary lung malignancy. Diagnostic methods included chest X-ray, chest
CT-scan, fiberoptic bronchoscopy, bronchial wash cytology, transbronchial
biopsy and fine needle aspiration biopsy. Conventional or video- assisted
mediastinoscopy were done as needed to rule out N2 lymph node status. For
primary lung malignancies, metastatic workup with chest and upper abdomen CT
scan that includes the adrenals, brain MRI, and bone isotope scan was done. Positron
Emission Tomography scan was done as needed.
The selection criteria to perform metastatectomy for patients with
secondary lung tumours were: the primary should be controlled, no extrathoracic
metastasis found, and all metastatic nodules could be resected at the same
time. Routine preoperative evaluation included a complete history and physical
examination, complete blood count with coagulation profile, liver function and
kidney function test, pulmonary function test and arterial blood gases. All the
patients were sent for cardiac evaluation preoperatively by a specialized
cardiologist. Cardiac evaluation included a complete history including risk
factors for coronary artery disease, cardio vascular physical examination,
electrocardiography, 2-dimensional echocardiography, treadmill test for risk
stratification, coronary angio CT scan and cardiac catheterization when needed.
Patients with pre existing cardiac diseases were excluded from the study and none
of the patients who were included in this study were on preoperative cardiac
medications. Pre-operative beta blockers were not used as a prophylactic
measure.
The mode of anaesthesia was single lung ventilation
using a double lumen endotracheal tube in all patients. A radial arterial line,
subclavian catheter, and a Foley’s catheter were inserted in all patients. The
patients were positioned in a lateral position according to the site and the
preferred incision was a posterolateral thoracotomy. The patients underwent
different types of major lung resection surgery for primary and secondary lung
cancer which included lobectomy, bilobectomy, pneumonectomy, segmentectomy and
wedge resection. All the patients were admitted to the intensive care unit
post-operatively. Post-operative
Complete Blood Count, electrolytes, kidney function test, arterial blood gases were
measured twice daily. Daily chest X-ray was done. Continuous cardiac monitoring
included pulse rate, rhythm, blood pressure, central venous pressure, and oxygen
saturation. Any postoperative cardiac
arrhythmias were documented during Intensive Care Unit stay, and managed by the
cardiology team accordingly using anti arrhythmic medications like Adenosine
and Isoptin, Amiodarone for atrial fibrillation or flutter and occasionally
electrical cardioversion. Simple descriptive statistics were used to analyze
the findings. Continuous variables were expressed as means and standard
deviations, and categorical variables were expressed as percentages.
Results
The sample included 35 males (72.9%) and 13 females (27.1%). Age ranged
from 21 to 82 years (mean 56.6 ± 14.9). Forty-three
patients (89.6%) were diagnosed to have primary lung malignancy, while five
patients (10.4%) had a secondary lung malignancy. The histopathologies of the
diagnosed tumors are shown in Table I. Left sided surgery was performed in 21 patients (43.7%), while right
sided resections were carried out in 27 patients (56.3%). Lobectomy was the
most commonly performed operation which was done in 27 patients (56.3%),
followed by pneumonectomy which was performed in 14 patients (29.2%) as
presented in Table II. Post operative cardiac arrhythmias occurred in 19
patients (39.6%). Atrial fibrillation was the most common reported cardiac arrhythmia
which occurred in 15 patients (31.2%), 2 patients (4.2%) developed supra
ventricular tachycardia and 2 patients (4.2%) developed atrial flutter. Ten
patients out of the 14 patients who underwent pneumonectomy developed cardiac
arrhythmias postoperatively, the most common of which was atrial fibrillation which occurred in eight patients. Table III shows that eight patients out of the 27 patients who underwent lobectomy developed cardiac arrhythmias, the most common of which was atrial fibrillation which occurred in six patients. Arrhythmias occurred in nine patients (18.7%) after right sided surgery and in ten patients (20.8%) after left sided surgery (Table IV). Fifteen males developed arrhythmias (31.2%), while only four females (8.3%) developed arrhythmias (Table V). Table VI demonstrated that twelve patients out of the 19 patients who developed arrhythmias were above 60 years of age. Fourteen patients (29.2%) developed the arrhythmias during the first 24 hours post resection, while five patients (10.4%) developed the arrhythmias after 24 hours. The average intensive care units stay was 2.82±0.94 days for the patients who did not develop cardiac arrhythmias; while for patients who developed cardiac arrhythmias was 5.00±1.25 days. Four patients (8.3%) died during the postoperative hospital stay; all of them developed cardiac arrhythmias postoperatively.
Table I. Histopathology of the resected tumors
|
Histopathology
|
Number
|
%
|
|
Squamous cell carcinoma
|
22
|
45.8
|
|
Adenocarcinoma
|
12
|
25.0
|
|
Carcinoid
|
4
|
8.3
|
|
Metastatic sarcoma
|
3
|
6.3
|
|
Adenosquamous carcinoma
|
2
|
4.2
|
|
Large cell carcinoma
|
2
|
4.2
|
|
Undifferentiated sarcoma
|
1
|
2.1
|
|
Metastatic choriocarcinoma
|
1
|
2.1
|
|
Metastatic giant cell tumor
|
1
|
2.1
|
|
Total
|
48
|
100
|
Table II. Types of surgery performed to resect the reported
tumors
|
Type of surgery
|
Right
|
Left
|
Total
|
%
|
|
Segmentectomy
|
0
|
1
|
1
|
2.1
|
|
Upper lobectomy
|
3
|
5
|
8
|
16.7
|
|
Middle lobectomy/lingulectomy
|
2
|
0
|
2
|
4.2
|
|
Lower lobectomy
|
9
|
8
|
17
|
35.4
|
|
Bilobectomy
|
2
|
0
|
2
|
4.2
|
|
Standard pneumonectomy
|
8
|
5
|
13
|
27.1
|
|
Transpericardial pneumonectomy
|
1
|
0
|
1
|
2.1
|
|
Wedge resection
|
2
|
2
|
4
|
8.3
|
|
Total
|
27
|
21
|
48
|
100
|
Table III.
Reported cardiac arrhythmias in relation to the performed resection type
|
Procedure
|
A.F*
|
S.V.T**
|
A.FL†
|
Total
|
%
|
|
Segmentectomy
|
0
|
0
|
0
|
0
|
0.0
|
|
Upper lobectomy
|
2
|
0
|
0
|
2
|
4.2
|
|
Middle lobectomy/lingulectomy
|
0
|
0
|
0
|
0
|
0.0
|
|
Lower lobectomy
|
4
|
1
|
1
|
6
|
12.5
|
|
Bilobectomy
|
1
|
0
|
0
|
1
|
2.1
|
|
Standard pneumonectomy
|
7
|
1
|
1
|
9
|
18.7
|
|
Transpericardial pneumonectomy
|
1
|
0
|
0
|
1
|
2.1
|
|
Wedge resection
|
0
|
0
|
0
|
0
|
0.0
|
|
Total
|
15
|
2
|
2
|
19
|
39.6
|
* Atrial Fibrillation, ** Supraventricular
Tachycardia, † Atrial Flutter
Eight out of the 15
patients who developed atrial fibrillation reverted spontaneously to normal
sinus rhythm within 24 hours, five patients reverted to sinus rhythm using Amiodarone
infusion, and two patients needed electrical cardioversion which was
successful. All of them were continued on either beta-blockers or calcium
channel blockers. Two patients developed atrial flutter.
Both of them received Amiodarone infusion (300 mg bolus and 1.0 mg/min for 24 hrs) but none reverted to sinus Rhythm. Electrical cardioversion was performed which was successful and they were kept on beta-blockers. Another two patients developed supraventricular tachycardia (SVT) which was reverted to normal sinus rhythm using Adenosine 12mg intravenously.
Table IV. Arrhythmias in relation to the site of surgery
|
Procedure
|
Right
|
Left
|
Total
|
%
|
|
Segmentectomy
|
0
|
0
|
0
|
0.0
|
|
Upper lobectomy
|
0
|
2
|
2
|
4.2
|
|
Middle lobectomy /lingulectomy
|
0
|
0
|
0
|
0.0
|
|
Lower lobectomy
|
4
|
2
|
6
|
12.5
|
|
bilobectomy
|
1
|
0
|
1
|
2.1
|
|
Standard pneumonectomy
|
4
|
5
|
9
|
18.7
|
|
Transpericardial pneumonectomy
|
0
|
1
|
1
|
2.1
|
|
Wedge resection
|
0
|
0
|
0
|
0.0
|
|
Total
|
9
|
10
|
19
|
39.6
|
Table V. Relation of arrhythmias to gender
|
Arrhythmia
|
Male
|
Female
|
Total
|
%
|
|
A.F*
|
11
|
4
|
15
|
31.2
|
|
S.V.T**
|
2
|
0
|
2
|
4.2
|
|
A.FL†
|
2
|
0
|
2
|
4.2
|
|
Total
|
15
|
4
|
19
|
39.6
|
*Atrial
Fibrillation, ** Supraventricular Tachycardia, † Atrial Flutter
Table VI. Relation of arrhythmias to age groups:
|
Age
|
A.F*
|
S.V.T**
|
A.FL†
|
Total
|
%
|
|
21-30
|
1
|
0
|
0
|
1
|
2.1
|
|
31-40
|
1
|
0
|
0
|
1
|
2.1
|
|
41-50
|
2
|
1
|
0
|
3
|
6.2
|
|
51-60
|
2
|
0
|
0
|
2
|
4.2
|
|
61-70
|
5
|
1
|
1
|
7
|
14.6
|
|
71-80
|
3
|
0
|
0
|
3
|
6.2
|
|
81-90
|
1
|
0
|
1
|
2
|
4.2
|
|
Total
|
15
|
2
|
2
|
19
|
39.6
|
*Atrial Fibrillation, ** Supraventricular Tachycardia,
† Atrial Flutter
Discussion
Cardiac arrhythmia after
thoracotomy for pulmonary resections is well documented, with atrial
fibrillation acknowledged to be the most common occurrence.(7,8) The
aetiology of these complications is still not clearly understood, although
several factors are likely to be involved.(9) Most authors
consider increased vagal tone, hypoxemia, hypercapnia, intraoperative fluid imbalance
and pericardial handling to be deciding factors. Intraoperative hypotension has
also been related to increased risk of arrhythmia.(10)
Postoperative
arrhythmias after major thoracic operations have been associated with major
morbidity and increased perioperative mortality.(11) In our
study, atrial fibrillation was the most commonly reported cardiac arrhythmia
after major lung resection surgery for primary and secondary lung malignancies.
This is comparable to the results that were
reported by most
of the authors.(1-12)
Although, Cardinale et
al.(12) reported statistically insignificant rhythm
abnormality rates between males and females after major lung resection in our
series, rhythm abnormalities were more common in the males after major lung
resection surgery. This finding is
comparable to the results of Bernard et al.(13) and
Roselli et al.(14) A possible explanation for this finding
is that males constituted the majority sample in our study.
Roselli et al.(14)
reported that right sided pneumonectomy and older age were statistically
significant risk factors to develop atrial fibrillation post lung resection
surgery in a series of 604 patients who underwent
different kinds of anatomic
lung resection. Similarly,
our results indicated that arrhythmias were more common after pneumonectomy and
among the older age group, however we did not find any notable difference
regarding the incidence of arrhythmias after right sided as opposed to left
sided surgery. This difference between our study and Roselli et al.’s study
may be stemming from our relatively small sample. A larger number is needed to compare the
results in a more efficient way.
In our series most of
the arrhythmias occurred in the first 24 to 48 hours postoperatively and the
incidence declined after that. These results are in agreement with the results
of other authors.(14,15) Regarding intensive care unit stay,
patients who developed rhythm abnormalities stayed more as compared with the
patients who did not. Some authors suggest the use of pre and postoperative beta-blockers
as a preventive measure, although several studies did not show good value for their
prophylactic use.(11,16)
Limitation
of the Study
The number of the studied sample is relatively small
as compared to other studies. After appropriate literature review, no national
studies were found for better comparison. We think that further prospective studies are
needed to compare cardiac arrhythmias after minor and major lung resection
surgery.
Conclusion
Post major lung resection cardiac arrhythmias are common. Preoperative evaluation and postoperative cardiac
monitoring are mandatory even among patients who have no pre-existing cardiac
diseases.
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