Objective
To determine whether elevated preoperative B-type natriuretic peptide (NP) measurements are an independent predictor of atrial fibrillation (AF) in patients having thoracic surgery.
Design
Systematic review and meta-analysis.
Setting
In-hospital and 30 days after thoracic surgery.
Participants
The 742 patients who participated in the 5 observational studies.
Interventions
None.
Measurements and Main Results
EMBASE, OVID Health Star, Ovid Medline, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ProQuest Dissertations and Theses A&I databases were searched for all studies of noncardiac thoracic surgery patients in whom a preoperative NP was measured up to 1 month before surgery, and that measured the incidence of postoperative AF. Studies were included regardless of their language, sample size, publication status, or study design. Study quality was evaluated using the Newcastle Ottowa Scale.
The combined incidence of postoperative AF was 14.5% (n = 108/742), and the NP thresholds used to predict AF varied among studies. An elevated preoperative NP measurement was associated with an OR of 3.13 (95% CI 1.38-7.12; I2 = 87%) for postoperative AF, with the sensitivity analysis reporting an OR of 9.51 (95% CI 4.66-19.40; I2 = 0).
Conclusion
Patients with an elevated preoperative NP measurement are at an increased risk of postoperative AF. There may be value in incorporating NP measurement into existing AF risk prediction models.

Background Postoperative continuous positive airway pressure (CPAP) can improve lung function. The aim of our study was to assess the efficacy of prophylactic CPAP on the Pa O 2 /FI O 2 ratio measured the day after surgery in patients undergoing lung resection surgery (LRS).
Methods The study population comprised 110 patients undergoing LRS. On arrival in the postanaesthesia care unit (PACU), patients were randomized to receive CPAP at 5–7 cm H2O during the first 6 h after surgery (CPAP group) or supplemental oxygen through a Venturi mask (Venturi group). The Pa O 2 /FI O 2 ratio was measured on arrival in the PACU, 7 h after admission, and the day after surgery. The Pa O 2 /FI O 2 ratio is the primary endpoint of our study. We also analysed the chest radiograph and assessed the postoperative course. We then analysed the impact of ventilatory management in the PACU depending on the respiratory risk of the patient.
Results Baseline characteristics were similar in both groups. Patients who received CPAP had significantly higher Pa O 2 /FI O 2 at 24 h after surgery compared with patients managed conventionally (Venturi group) (48.6±14 vs 42.3±12, P=0.031), but there were no differences at 7 h. On subgroup analysis, we found that the benefits of CPAP were greater in higher risk patients. The incidence of postoperative pulmonary complications and stay in the PACU and hospital were similar in both groups.
Conclusions In patients undergoing LRS, prophylactic CPAP during the first 6 h after surgery with a pressure of 5–7 cm H2O improved the Pa O 2 /FI O 2 ratio at 24 h. This effect was more evident in patients with increased risk of postoperative pulmonary complications.

Abstract
BACKGROUND: Postoperative acute kidney injury (AKI) is associated with increased perioperative morbidity and mortality in a variety of surgical settings, but has not been well studied after lung resection surgery. In the present study, we defined the incidence of postoperative AKI, identified risk factors, and clarified the relationship between postoperative AKI and outcome in patients undergoing lung resection surgery.

METHODS: A retrospective, observational study of patients who underwent lung resection surgery between January 2006 and March 2010 in a tertiary care academic center was conducted. Postoperative AKI was diagnosed within 72 hours after surgery based on the Acute Kidney Injury Network creatinine criteria. Logistic regression was used to model the association between perioperative factors and the risk of AKI within 72 hours after surgery. The relationship between postoperative AKI and patient outcome including mortality, days in hospital, and the requirement of reintubation was investigated.

RESULTS: A total of 1129 patients (pneumonectomy n = 71, bilobectomy n = 30, lobectomy n = 580, segmentectomy n = 35, wedge resection/bullectomy n = 413) were included in the final analysis. Patients were an average of 61 years (SD 15) and 50% were female. AKI was diagnosed in 67 patients (5.9%) based on Acute Kidney Injury Network criteria (stage 1, n = 59; stage 2, n = 8; and stage 3, n = 0) within 72 hours after surgery, and only 1 patient required renal replacement therapy. Multivariate analysis demonstrated an independent association between postoperative AKI and hypertension (adjusted odds ratio [OR] 2.0, 95% confidence interval [CI]: 1.1-3.8), peripheral vascular disease (OR 4.4, 95% CI: 1.8-10), estimated glomerular filtration rate (OR 0.8, 95% CI: 0.69-0.93), preoperative use of angiotensin II receptor blockers (OR 2.2, 95% CI: 1.1-4.4), intraoperative hydroxyethyl starch administration (OR 1.5, 95% CI: 1.1-2.1), and thoracoscopic (versus open) procedures (OR 0.37, 95% CI: 0.15-0.90). Development of AKI was associated with increased rates of tracheal reintubation (12% vs 2%, P < 0.001), postoperative mechanical ventilation (15% vs 3%, P < 0.001), and prolonged hospital length of stay (10 vs 8 days, P < 0.001). There was no difference in mortality between the 2 groups (3% vs 1%, P = 0.12). CONCLUSIONS: Preoperative risk factors for AKI after lung resection surgery overlap with those established for other surgical procedures. Perioperative management seems to influence the risk of AKI after lung resection; in particular, the use of synthetic colloids may increase the risk, whereas thoracoscopic procedures may decrease the risk of AKI. Early postoperative AKI is associated with respiratory complications and prolonged hospitalization.

Background. Meta-analysis and systematic reviews of epidural compared with paravertebral
blockade analgesia techniques for thoracotomy conclude that although the analgesia is
comparable, paravertebral blockade has a better short-term side-effect profile. However,
reduction in major complications including mortality has not been proven.
Methods. The UK pneumonectomy study was a prospective observational cohort study in
which all UK thoracic surgical centres were invited to participate. Data presented here
relate to the mode of analgesia and outcome. Data were analysed for 312 patients
having pneumonectomy at 24 UK thoracic surgical centres in 2005. The primary endpoint
was a major complication.
Results. The most common type of analgesia used was epidural (61.1%) followed by
paravertebral infusion (31%). Epidural catheter use was associated with major
complications (odds ratio 2.2, 95% confidence interval 1.1–3.8; P¼0.02) by stepwise
logistic regression analysis.
Conclusions. An increased incidence of clinically important major post-pneumonectomy
complications was associated with thoracic epidural compared with paravertebral
blockade analgesia. However, this study is unable to provide robust evidence to change
clinical practice for a better clinical outcome. A large multicentre randomized controlled
trial is now needed to compare the efficacy, complications, and cost-effectiveness of
epidural and paravertebral blockade analgesia after major lung resection with the
primary outcome of clinically important major morbidity.

Background: In order to assess the short term risks of pneumonectomy for lung cancer in
contemporary practice a one year prospective observational study of pneumonectomy outcome
was made. Current UK practice for pneumonectomy was observed to note patient and treatment
factors associated with major complications.
Methods: A multicentre, prospective, observational cohort study was performed. All 35 UK
thoracic surgical centres were invited to submit data to the study. All adult patients undergoing
pneumonectomy for lung cancer between 1 January and 31 December 2005 were included. Patients
undergoing pleuropneumonectomy, extended pneumonectomy, completion pneumonectomy
following previous lobectomy and pneumonectomy for benign disease, were excluded from the
study.
The main outcome measure was suffering a major complication. Major complications were defined
as: death within 30 days of surgery; treated cardiac arrhythmia or hypotension; unplanned intensive
care admission; further surgery or inotrope usage.
Results: 312 pneumonectomies from 28 participating centres were entered. The major
complication incidence was: 30-day mortality 5.4%; treated cardiac arrhythmia 19.9%; unplanned
intensive care unit admission 9.3%; further surgery 4.8%; inotrope usage 3.5%. Age, American
Society of Anesthesiologists physical status ≥ P3, pre-operative diffusing capacity for carbon
monoxide (DLCO) and epidural analgesia were collectively the strongest risk factors for major
complications. Major complications prolonged median hospital stay by 2 days.
Conclusion: The 30 day mortality rate was less than 8%, in agreement with the British Thoracic
Society guidelines. Pneumonectomy was associated with a high rate of major complications. Age,
ASA physical status, DLCO and epidural analgesia appeared collectively most associated with major complications

OBJECTIVE: Acute respiratory distress syndrome (ARDS) is a major cause of death following lung resection. At this institution we reported an incidence of 3.2% and a mortality of 72.2% in a review of patients who underwent pulmonary resection from 1991 to 1997 [Kutlu C, Williams E, Evans E, Pastorino U, Goldstraw P. Acute lung injury and acute respiratory distress syndrome after pulmonary resection. Ann Thorac Surg 2000;69:376-80]. The current study compares our recent experience with this historical data to assess if improved recognition of ARDS and treatment strategies has had an impact on the incidence and mortality. METHODS: We identified and studied all patients who developed ARDS following a lung resection of any magnitude between 2000 and 2005 using the 1994 consensus definition: characteristic chest X-ray or CT, PaO2/FiO2 < 200 mmHg, pulmonary capillary wedge pressure < 18 mmHg and clinical acute onset. Overall incidence and mortality were recorded. Univariate analyses (t-test or chi(2), as appropriate) were carried out to identify correlations between pre-, peri- and postoperative variables and outcomes. RESULTS: We performed 1376 lung resections during the study period. Of these 705 (51.2%) were for lung cancer and 671 (48.8%) for other diseases. Twenty-two patients fulfilled the criteria for ARDS with 10 deaths in this group. The incidence and mortality from ARDS had fallen significantly over the two study periods (incidence from 3.2% to 1.6%, p=0.01; mortality from 72% to 45%, p=0.05). Although no significant correlations with incidence and mortality were identified, we found a number of significant trends. In keeping with the ARDS network study recommendations, postoperative tidal volumes were maintained at a lower level when a higher number of pulmonary segments were excised (p=0.001). Furthermore, consistent with findings in previous studies, the highest incidence and death from ARDS were in pneumonectomy patients (incidence 11.4%; mortality 50%). Although the incidence and mortality from ARDS following pneumonectomy were not significantly different between the two study periods (p=0.08, p=0.35), we found that fewer pneumonectomies were performed in the later period (pneumonectomy rate of 6.4% vs 17.4%). CONCLUSIONS: The incidence and mortality of ARDS have decreased in our institution. We postulate that this is due to more aggressive strategies to avoid pneumonectomy, greater attention to protective ventilation strategies during surgery and to the improved ICU management of ARDS.

ats-07.docAlam N, Park BJ, Wilton A, et al. Ann Thorac Surg 2007; 84: 1085-91

Alvarez JM. Tan J. Kejriwal N. Ghanim K. Newman MA. Segal A. Sterret G. Bulsara MK
Journal of Thoracic & Cardiovascular Surgery. 133(6):1439-47, 2007 Jun.

OBJECTIVES: Idiopathic postpneumonectomy pulmonary edema is a leading cause of mortality after pneumonectomy. Postoperative hyperinflation of the remaining lung is an etiologic factor. We have demonstrated avoidance of postpneumonectomy pulmonary edema solely by changing management of the pneumonectomy space to a balanced drainage system. In sheep, we tested the following hypothesis: (1) Postoperative induced hyperinflation of the remaining lung can cause postpneumonectomy pulmonary edema. (2) A balanced drainage system can prevent its development. METHODS: We performed 37 right-sided pneumonectomies in adult sheep. In experiment 1, after surgery, 10 sheep had continuous suction (5 kPa) applied through an intercostal catheter placed in the empty hemithorax to induce mediastinal shift and hyperinflation of the left lung without adverse hemodynamic sequelae. In experiment 2, 27 sheep were randomly allocated into 3 equal groups regarding management of the residual empty right hemithorax: balanced drainage, no intercostal drainage, and clamp-release intercostal underwater drainage. A fourth group of 9 sheep served as a sham controls placebo with the same anesthetic and a right thoracotomy. RESULTS: All sheep tolerated surgery without adverse event. In experiment 1, there was significant mediastinal shift at necropsy in all sheep and 60% (n = 6) had postpneumonectomy pulmonary edema develop in the left lung (P = .023 vs sham). In experiment 2, incidences of postpneumonectomy pulmonary edema were as follows: 0 in balanced group (P = .057 vs other groups), 3 (30%) in no-drainage group, and 3 (30%) in clamp-release group. Only the 12 sheep with postpneumonectomy pulmonary edema had respiratory distress; the rest had uneventful recoveries. CONCLUSION: In a sheep model of postpneumonectomy pulmonary edema, hyperinflation from mediastinal shift is an etiologic factor. A balanced drainage system averts postpneumonectomy pulmonary edema. This is the first time such a causal relationship has been demonstrated, supporting our continued use of balanced drainage after pneumonectomy.

Authors: Iglesias, M.; Martinez, E.; Badia, J.R.; Macchiarini, P.
Abstract (English): Background: The purpose of this study was to evaluate the feasibility of integrating an artificial, pumpless extracorporeal membrane ventilator (Novalung) to near static mechanical ventilation and its efficacy in patients with severe postresectional acute respiratory distress syndrome (ARDS) unresponsive to optimal conventional treatment. Methods: Indications were severe postresectional and unresponsive acute respiratory distress syndrome, hemodynamic stability, and no significant peripheral arterial occlusive disease or heparin-induced thrombocytopenia. Management included placement of the arteriovenous femoral transcutaneous interventional lung-assist membrane ventilator, lung rest at minimal mechanical ventilator settings, and optimization of systemic oxygen consumption and delivery. Results: Among 239 pulmonary resections performed between 2005 and 2006, 7 patients (2.9%) experienced, 4 +/- 0.8 days after 5 pneumonectomies and 2 lobectomies, a severe (Murray score, 2.9 +/- 0.3) acute respiratory distress syndrome unresponsive to 4 +/- 2 days of conventional therapy. The interventional lung-assist membrane ventilator was left in place 4.3 +/- 2.5 days, and replaced only once for massive clotting. During this time, 29% +/- 0.3% or 1.4 +/- 0.36 L/min of the cardiac output perfused the device, without hemodynamic impairment. Using a sweep gas flow of 10.7 +/- 3.8 L/min, the device allowed an extracorporeal carbon dioxide removal of 255 +/- 31 mL/min, lung(s) rest (tidal volume, 2.7 +/- 0.8 mL/kg; respiratory rate, 6 +/- 2 beats/min; fraction of inspired oxygen, 0.5 +/- 0.1), early (<24 hours) significant improvement of respiratory function, and reduction of plasmatic interleukin-6 levels (p < 0.001) and Murray score (1.25 +/- 0.1; p < 0.003). All but 1 patient (14%) who died of multiorgan failure were weaned from mechanical ventilation 8 +/- 3 days after removal of the interventional lung-assist membrane ventilator, and all of them were discharged from the hospital. Conclusions: The integration of this device to near static mechanical ventilation of the residual native lung(s) is feasible and highly effective in patients with severe and unresponsive acute respiratory distress syndrome after pulmonary resection.

Author
Ciriaco P. Mazzone P. Canneto B. Zannini P
Institution
Division of Thoracic Surgery, University of Milan, Scientific Institute H.S. Raffaele, Via Olgettina 60, 20132, Milan, Italy
Title
Supraventricular arrhythmia following lung resection for non-small cell lung cancer and its treatment with amiodarone.
Source
European Journal of Cardio-Thoracic Surgery, 18(1):12-16, 2000 July 1.
Abstract
Objective: From January 1998 to February 1999, 160 patients undergoing lung resection for non-small cell lung cancer were studied to define factors that increase the risk of postoperative supraventricular arrhythmia (SA) and to assess the effectiveness of amiodarone as an antiarrhythmic drug. Methods: All patients were monitored intraoperatively and postoperatively up to day 3. Onset of SA was documented with ECG. Amiodarone was administered to those who developed SA with a loading dose of 5 mg/kg in 30 min and a maintenance dose of 15 mg/kg in 24 h. Results: Mean age was 64 years (range 27-83 years). There were nine wedge resections, six segmentectomies, 127 lobectomies and 18 pneumonectomies. Twenty-two patients (13%) had SA, all of which were atrial fibrillations. The incidence of supraventricular arrhythmia with pneumonectomy and lobectomy was 33 and 12%, respectively (P=0.02). None of the patients who had a minor resection developed SA. The peak incidence of onset of SA!
occurred on postoperative day 2 and lasted from 1 to 12 days (average 3.4 days). Sinus rhythm was achieved with amiodarone in 20 patients (90.9%) with no side effects. Two patients received electrical cardioversion because hemodynamically unstable. Mean preoperative pO(2) and pCO(2) were lower in patients with SA: pO(2) 80.8 vs. 85 mmHg (P=0.04); pCO(2) 35.5 vs. 38 mmHg (P=0.01). Patients with concomitant cardiopulmonary diseases presented an odds ratio for postoperative arrhythmia of 12.4 (confidence interval 4.5-34.1) (P<0.0001). Conclusion: Concomitant cardiopulmonary diseases, lower pO(2), pCO(2) and extent of surgery increase the risk of postoperative SA after lung resection for non-small cell lung cancer. Cardiac monitoring in patients at risk is recommended. Amiodarone was both safe and effective in establishing and maintaining sinus rhythm.