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Preoperative Echocardiographic Evaluation of Patients Referred for Lung Volume Reduction Surgery FREE TO VIEW

David S. Bach; Jeffrey L. Curtis; Paul J. Christensen; Mark D. Iannettoni; Richard I. Whyte; Ella A. Kazerooni; William Armstrong; Fernando J. Martinez
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Affiliations: From the Department of Internal Medicine, Division of Cardiology, University of Michigan Medical Center, Ann Arbor, Michigan,  From the Department of Internal Medicine, Divisions of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, Michigan,  From the Department of Surgery, Section of Thoracic Surgery, University of Michigan Medical Center, Ann Arbor, Michigan,  From the Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan

Fernando J. Martinez, MD, TC 3916, 1500 E. Medical Center Dr., Ann Arbor, MI 48109-0360; e-mail: fmartine@umich.edu

1998 by the American College of Chest Physicians

Chest. 1998;114(4):972-980. doi:10.1378/chest.114.4.972
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Background: The most efficient preoperative assessment for lung volume reduction surgery (LVRS) in patients with advanced emphysema is undefined. This study analyzed the preoperative assessment of patients by surface echocardiography (without and with dobutamine infusion), the results of which were used to exclude patients with significant pre-existing cardiac disease, a contraindication to LVRS, from the surgery.

Setting: A university-based, tertiary care referral center.

Methods: Patients with emphysema who met initial LVRS screening criteria underwent resting and stress surface echocardiography with Doppler imaging. Patients were evaluated prospectively for perioperative cardiac complications.

Results: Between July 1994 and December 1996, 503 candidates for LVRS were evaluated. Of these, 207 patients (81.8%) who had echocardiography performed at our institution formed the primary study group. Images were adequate for the analysis of chamber sizes and function in 206 patients (99.5%) undergoing resting echocardiography, and the images were adequate for wall motion analysis in 172 of 174 patients (98.9%) undergoing functional testing. Right heart abnormalities were common (40.1%). Significant pulmonary hypertension (> 35 mm Hg) was uncommon (5 patients, 5.4%) among the 92 patients who subsequently underwent right heart catheterization. Occult ischemia, left ventricular dysfunction, and valvular abnormalities also were uncommon. Thus, although Doppler imaging estimates of right ventricular systolic pressure were imperfect, echocardiographic findings of normal right heart anatomy and function excluded significant pulmonary hypertension. Ninety patients (43%) eventually underwent LVRS (70 bilateral and 20 unilateral). A total of 13 perioperative cardiac events occurred in 10 patients, 6 of whom had undergone preoperative echocardiography. No patient suffered acute myocardial infarction or cardiac death.

Conclusions: Despite potential limitations due to severe obstructive lung disease, surface echocardiographic imaging is a feasible, noninvasive tool in this patient population to identify patients with evidence of cor pulmonale that suggests pulmonary hypertension. The routine use of surface resting and stress echocardiography for preoperative screening obviates the need for invasive right heart catheterization in many patients and results in a low incidence of significant perioperative cardiac complications.




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