Chest
Clinical Investigations: Surgery: ArticlesCoronary Artery Disease in Patients Undergoing Lung Volume Reduction Surgery for Emphysema
Section snippets
Patient Selection for LVRS
Inclusion Criteria: According to criteria published previously,1, 5 potential candidates for LVRS had the following profile: the patient has severe COPD with an FEV1 of <35% predicted and is considerably hyperinflated (residual lung volume >200%, total lung capacity >130% predicted). Radiologic signs of pulmonary emphysema with flat diaphragms are present on conventional chest radiograph and emphysema is confirmed on a high-resolution CT scan. The patient is highly motivated and has stopped
Results
Between January 1995 and June 1996, 86 patients were referred for evaluation for LVRS. Thirty-six patients were excluded from a further workup owing to various noncardiac reasons (eg, impairment not severe enough, perioperative risk not accepted, emotional instability) (Fig 1). Four patients were not evaluated further for cardiac reasons: two had a documented history of transmural MI and two patients suffered from ischemic left heart failure.
The remaining population that was evaluated further
Coronary Angiography Findings and Left Heart Function in Symptomatic Patients
In all three symptomatic patients, CAD was documented angiographically. None of them had impaired left ventricular systolic function. One patient underwent preoperative bypass grafting and one underwent preoperative stenting of the LAD.
Cardiovascular Risk Profile
All asymptomatic patients were former smokers. There were no differences between asymptomatic patients with CAD and those without CAD with regard to age and sex (Table 3). The 35 patients in whom no CAD was found by coronary angiography had smoked somewhat less (43 py) than patients with significant CAD (59 py). Furthermore, the percentage of patients with a smoking history of more than the arbitrary cutoff of 45 py tended to be higher in the group with documented CAD (p=0.09).
The prevalence of
Discussion
We found a high prevalence of asymptomatic CAD in a population of candidates for LVRS, who were mainly elderly patients and exclusively former heavy smokers.
LVRS is a novel surgical approach that is successfully applied in a selected group of patients with COPD who are considerably hyperinflated owing to severe pulmonary emphysema.1, 2, 3, 4, 5 LVRS can be performed by median sternotomy1, 2 or by video-assisted thoracoscopy.3, 4, 5 For both operations, the patient is intubated with a
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Cited by (60)
Anaesthesia for lung volume reduction surgery and endobronchial valves
2018, BJA EducationThe effect of lung volume reduction surgery on chronotropic incompetence
2012, Respiratory MedicineEmphysema, lung volume reduction and anaesthesia
2012, Trends in Anaesthesia and Critical CareCitation Excerpt :Co-existing cardiovascular disease is likely in this group of patients and should be specifically investigated. Given that up to 15% of COPD patients have been demonstrated to have asymptomatic coronary artery disease24 it seems prudent to investigate all patients presenting for surgery, though availability of resources may not allow this. Dynamic cardiac testing would elicit those with coronary disease, but given limited exercise capacity, a pharmacological stress test may be more likely to reveal disease.
Comorbidities in COPD: A new challenge in clinical practice
2011, Revue de Pneumologie CliniqueSuccessful combined bilateral lung volume reduction and coronary artery bypass grafting surgery: Implications and advantages
2009, Journal of Thoracic and Cardiovascular SurgeryCitation Excerpt :Most patients with end-stage emphysema have a history of smoking and are therefore at increased risk for CAD. Fifteen percent of the patients who were suitable to undergo LVRS were found to have coexisting CAD in a report by Turnheer and colleagues.1 Because dyspnea is often multifactorial, some patients will have severe and disabling symptoms from a combination of cardiac and pulmonary diseases.
Combined Cardiac and Lung Volume Reduction Surgery
2009, Thoracic Surgery ClinicsCitation Excerpt :A number of authors have now shown that in highly selected patients, a combined cardiac surgery and LVRS procedure is feasible, can be done safely, and can result in improvements in pulmonary function similar to those reported after isolated LVRS procedures.3–9 The fact that cardiac operations can be performed safely in conjunction with lung volume reduction has implications for two groups of patients who have severe emphysema:1 those who are denied LVRS on the basis of concomitant cardiac disease and2 those who are denied a cardiac operation because of a perceived excessive operative risk secondary to concomitant severe emphysema. The first group of patients includes those who have historically been turned down for LVRS because of concomitant valvular or coronary disease that would either increase the patients' risks from LVRS or limit their potential for full postoperative rehabilitation and recovery.
Supported by grants from the Swiss National Science Foundation (3200-043358;95/1) and the Zurich Lung League.