Chest
Volume 112, Issue 1, July 1997, Pages 122-128
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Clinical Investigations: Surgery: Articles
Coronary Artery Disease in Patients Undergoing Lung Volume Reduction Surgery for Emphysema

https://doi.org/10.1378/chest.112.1.122Get rights and content

Objectives

Most patients with severe pulmonary emphysema referred for lung volume reduction surgery (LVRS) have a long-standing history of cigarette smoking. Coronary artery disease (CAD) predisposes to perioperative cardiac complications. Since symptoms and signs of myocardial ischemia are often absent in patients with severe ventilatory impairment even during exercise, we investigated the prevalence of CAD in candidates for LVRS by angiography.

Design

We prospectively studied the prevalence of CAD by angiography and assessed the CAD risk factor profile in 41 candidates for LVRS (26 men, 15 women; mean age, 66±6.8 years; range, 52 to 76 years), who had no current symptoms or a history of myocardial ischemia.

Results

In six patients (15%), asymptomatic but significant coronary lesions (>70% stenosis) were detected. In five patients, these findings altered the clinical management. Patients with CAD had significant higher cholesterol levels, tended to have smoked more, and had more often additional vascular risk factors.

Conclusions

We found a high prevalence of angiographically significant but clinically silent CAD in this particular population of heavy smokers with advanced 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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      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.

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      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.

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      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.

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    Supported by grants from the Swiss National Science Foundation (3200-043358;95/1) and the Zurich Lung League.

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