Major thoracic surgery is associated with a 5-10% incidence of post-operative cardiac events. It has been shown to be difficult, based on clinical criteria alone, to determine the severity of cardiac disease. We hypothesized that routine stress testing would identify patients at increased risk for cardiac complications and would lead to subsequent interventions, ultimately improving outcomes.
In 1998, a prospective study of routine cardiac stress testing in all patients undergoing major thoracic surgery was instituted, regardless of cardiac symptoms. From July, 1998 to February, 2003, 344 patients underwent major pulmonary or esophageal resections. These included VATS lobectomies/segmentectomies (240), open lobectomies/pneumonectomies (79), and Ivor Lewis esophagectomies (25). Pre-operative stress testing consisted of pharmacologic thallium scintigraphy or dobutamine echocardiography. The patients with positive stress tests underwent further evaluations/interventions and were treated wth PA catheter monitoring and beta blockers. Our thoracic surgical database was reviewed for: pre-operative presentations, stress test results, interventions, intra-operative events, post-operative course, complications, and mortality.
The overall mortality in the 344 patients was 7 (2.0%), with 2 (0.6%) cardiac events. 10 patients (2.9%) had an overtly positive stress test: 8 underwent cardiac catheterization, 3 of whom had placement of a coronary stent. In this group there was one MI and no mortality. In the remaining 334 (97.1%) with a negative stress test, there was one MI (0.3%) with subsequent death. All cardiac events occurred in patients with pulmonary resections.CONCLUSIONS: There is a relatively low rate of cardiac events in this series of major thoracic surgeries. This may be due to identification of high risk patients by routine stress testing and subsequent interventions and modifications of peri-operative care.
The results of this study suggest that routine pre-operative stress testing defines which patients would benefit from further cardiac study and interventions. Further study and analysis is warranted.
N.M. Katz, None.