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Dr. Rocco is Consultant Thoracic Surgeon, Honorary Senior Clinical Lecturer, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, United Kingdom.
Correspondence to: Gaetano Rocco, MD, FCCP, Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield Teaching Hospitals, Herries Rd S5 7AU, Sheffield, United Kingdom; e-mail:grocco{at}tany.fsnet.co.uk
In the current surgical literature, numerous attempts at identifying predictors of postoperative outcome in terms of morbidity and mortality are being reported. Such commendable efforts have led many investigators1 2 to devise a scoring system for thoracic surgical patients in order to reduce surgical risks and better select surgical candidates. Although larger series will be needed in order to assess the reproducibility of a scoring system under different epidemiologic scenarios, the commitment toward a new interpretation of preoperative workup investigations seems obvious. In this setting, the article by Sekine and colleagues in this issue of CHEST (see page 1783) gives statistical recognition to a well-known fact in clinical practice. In their series, they found that patients with an FEV1 of < 70% of predicted (COPD patients) are at higher risk for postoperative supraventricular tachyarrhythmias (SVT) as compared to patients with "normal" FEV1 levels (non-COPD patients). Indeed, in the general thoracic surgical practice, patients with an FEV1 of < 70% may represent the majority of the surgical candidates. However, Sekine and coworkers have restricted their analysis to the risk factors for SVT in COPD patients, leaving to future investigators the task of further stratifying this subgroup of patients. This could only happen if a refinement of the preoperative workup will take place. In this context, the resort to pulmonary function testing criteria alone seems inadequate.3 In fact, the pathogenesis of SVT in resected patients is deemed to be multifactorial. Transient hypoxemia, hemodynamic instability, sympathetic hyperreactivity, and intraoperative alterations (ie, intrapericardial dissection) have all been related to a different extent to the onset of SVT.
Whatever the cause, the clinical relevance of SVT after pulmonary resection mandates a thorough reevaluation of the available prophylactic regimens, especially in view of the digoxin resistance of postoperative SVT and the increased operative mortality following bilobectomy or pneumonectomy in COPD patients. In this setting, should echocardiography be employed more extensively when a patient is a candidate for pneumonectomy? Will exercise testing be of help in identifying patients at high risk for postoperative SVT? Is a different spectrum of intensity of prophylaxis and treatment justified when dealing with pneumonectomy patients as opposed to lesser resections? With these questions unanswered, the search for the single predictor of postoperative arrhythmias after pulmonary resection is far from being called off.
References
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