Cardiac Complications After Lung Surgery

Author: Ammar Asban, MD & Brian Mitzman, MD
Institution: University of Utah
Date Reviewed: March 2025
Original Case: Raghav Murthy, MD; Derek Williams, MD; David Graham, MD; Brian Bethea, MD
Learning Domain: General Thoracic/Adult Cardiac
Learning Objective: Perioperative cardiac events
PowerPoint File: File TS02 - Cardiac Complications after Lung Surgery.pptx

 

Background

  • 71-year-old male, 6 month h/o 
    • Cough
    • Increasing SOB / DOE
    • No systemic symptoms
  • Past Medical History
    • COPD, HTN, early dementia    
    • 10 pack-year smoker
    • 3 alcoholic beverages/day

 

History and Exam

  • Labs
    • PFT’s:
      • FVC  83% predicted 
      • FEV1  69% predicted
      • DLCO  79% predicted
  • EKG: normal
  • ECHO: EF 60%
  • Bronchoscopy: LLL submucosal mass, cytology +ve adenocarcinoma

 

Chest X-Ray

CT Scan

PFT - 5.5 SUV

 

Discussion Points for Conference

  • What stage is this neoplasm?
  • Which resections would this patient tolerate based on PFT’s?
  • What is an appropriate cardiac work-up?
    • Functional vs. anatomic testing
  • List the general complications  of pneumonectomy
  • List cardiac specific complications of pneumonectomy
    • Simple vs. complex complications
  • What is the mortality of a pneumonectomy versus a sleeve resection?
  • What is the long and short term post-op follow-up?

 

Operation

  • Pt had a mediastinoscopy January 13th.  Level 4R, 7, 4L, 2R, and 2L were sampled and negative for malignancy
  • Left pneumonectomy was performed February 3rd

NOTE: This case was performed before the era of neoadjuvant chemoimmunotherapy, and in the modern era with likely N1+ disease, Checkmate816 protocol should be strongly considered via multidisciplinary discussion.

  • After completing the pneumonectomy and while the chest is still open, the patient has a PEA arrest.
  • What do you do?

 

Complication Part 1

  • Pt receives CPR and emergent left heart cath
    • Found 80% RCA stenosis and placed a BMS. 
    • Why Bare Metal?
    • What are the differences between Bare Metal and Drug Eluting?
    • What is the risk of stent occlusion?
    • What is the role of plavix, integrellin, ASA?
       
  • Immediately post stent placement...
    • Pt has persistent hypotension
    • What do you do?
    • What is the differential?

 

Differential

  • Ongoing ischemia
    • Missed lesion at cath/incomplete re-vascularization
    • Early stent occlusion
    • Coronary artery dissection
  • Hypovolemia
    • Bleeding, vasodilated, oversedation 
    • Cardiac Tamponade
    • Mediastinal shift post pneumonectomy

 

Complication Part 2

  • PA Catheter showing tamponade
  • Echocardiogram showing blood around heart
  • What do you do?

 

Operation Continued

  • Subxiphoid window
  • Converted to Sternotomy, 1 cm tear found at base of left atrium
  • Repaired

What bleeding can be repaired through the original left thoracotomy and what bleeding is better repaired through a median sternotomy?  
 

Pathology

  • pT3N2M0 : Stage IIIB
  • 3/11 LN + including level 7

The 8th edition of the AJCC staging system for non-small cell lung cancer 

  • Further therapy?
    • Chemotherapy
    • Radiation Therapy

 

Post Operative Course

  • Vasoactive meds weaned off by POD 7
  • L CT for intermittent drainage of hemothorax
  • POD 10: cholangitis
  • POD 14: extubated
  • POD 26: d/c to rehab

 

Discharge  CXR

 

Perioperative Risk

Calculate this patient’s perioperative risk using the American College of Surgery Risk Calculator: https://riskcalculator.facs.org/RiskCalculator/PatientInfo.jsp

For additional resources, the STS offers several risk calculators based on the STS National Database: https://www.sts.org/resources/calculators-tools/sts-risk-calculators

 

Contraindications to Noncardiac Surgery

  • High-Risk Cardiac Conditions Considered Contraindications to Noncardiac Surgery
    • Acute coronary syndrome
    • Acute decompensated heart failure
    • Tachyarrhythmias or bradyarrhythmias associated with hypotension or requiring urgent medical attention (eg, ventricular tachycardia or high-grade atrioventricular block)
    • Symptomatic, severe aortic stenosis (mean gradient >40 mm Hg or peak velocity >4 m/s)

Perioperative Cardiovascular Risk Assessment and Management for Noncardiac Surgery A Review. Nathaniel R. Smilowitz, MD, MS; Jeffrey S. Berger, MD, MS. JAMA. 2020;324(3):279-290.

 

Perioperative Cardiac Events

The Lee Index is a cardiac risk calculator designed by Lee Goldman with 6 possible points.

  • High-risk surgery
  • History of ischemic heart disease
  • History of congestive heart failure
  • History of cerebrovascular disease
  • Preoperative treatment with insulin
  • Preoperative serum creatinine >2.0 mg/dl (>177 µmol/L).     

     

PJ Devereaux et al: Peri-op cardiac events in patients undergoing non cardiac surgery: CMAJ/JAMC 2005; 173(6): 627- 34.

Perioperative Major Adverse Cardiovascular and Cerebrovascular Events Associated With Noncardiac Surgery. Smilowitz et al. JAMA Cardiol. 2017;2(2):181-187.


Incidence of major adverse cardiac events following non-cardiac surgery. Lorraine Sazgary et al. European Heart Journal: Acute Cardiovascular Care (2021) 10, 550–558.

Factors Associated with Perioperative Cardiac Complications in Patients

Cardiac Complications in Patients Undergoing Major Noncardiac Surgery. P.J. Devereaux, M.D., Ph.D., and Daniel I. Sessler N Engl J Med 2015;373:2258-69.

 

Learning Points

  • Cardiac complications of thoracic surgery are not inconsequential
  • Pre-operative Index of Suspicion is important
  • Prognosis after major perioperative cardiac event is poor
  • Multiple factors contribute to peri-operative cardiac events