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Ann Thorac Surg 1998;66:1766-1771
© 1998 The Society of Thoracic Surgeons

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Original articles: general thoracic

Incidence and predictors of supraventricular dysrhythmias after pulmonary resection

^a Division of Cardiothoracic Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA

Address reprint requests to Dr Curtis, Division of Cardiothoracic Surgery, University of Missouri School of Medicine, MA312 HSC, One Hospital Drive, Columbia, MO 65212
e-mail: (curtisj{at}health.missouri.edu)

Presented at the Forty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Naples, FL, Nov 6–8, 1997.

	Abstract

Top Abstract Introduction Materials and methods Statistical analysis Results Comment Conclusions References

 
Background. Patients undergoing pulmonary resection were evaluated prospectively in an effort to determine the incidence of and predictors for the development of postoperative supraventricular dysrhythmias. Specifically, we wished to test the hypothesis that the incidence of postoperative supraventricular dysrhythmias is dependent on the magnitude of pulmonary resection.

Methods. One hundred sixteen patients undergoing pulmonary resection had continuous Holter monitoring preoperatively, the day of operation, and the second postoperative day, as well as continuous cardiac monitoring throughout hospitalization. Holter interpretation was blinded to extent of resection.

Results. Twenty-six patients underwent pneumonectomy, 7 bilobectomy, 47 lobectomy, and 36 wedge resection. Twenty-six patients (22.4%) had supraventricular dysrhythmias, all atrial fibrillation ± flutter. The incidence of atrial fibrillation with pneumonectomy, bilobectomy, single lobectomy, and wedge resection was 46.1%, 14.3%, 17.0%, and 13.8%, respectively (p < 0.005 pneumonectomy versus others). Overall, 31% of patients having pneumonectomy required pharmacologic therapy for dysrhythmia compared with 16% of patients having lesser resections, (p = 0.03). The peak incidence of onset of atrial fibrillation occurred on postoperative days 2 and 3 and lasted for less than 1 to 7 days, average 2.5 days. The average age of patients with dysrhythmias (64 years) was greater than those without (58 years) (p = 0.039). Thirty pre- and postoperative variables tested were not found to be significant predictors for development of postoperative atrial fibrillation.

Conclusions. Atrial fibrillation occurs commonly after pulmonary resections but is not predictable. Development of atrial fibrillation is not dependent on the magnitude of pulmonary resection but is associated with the procedure pneumonectomy for reasons not elucidated.

	Introduction

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Supraventricular dysrhythmias following pulmonary resection have been well documented, although their reported incidence has varied widely [1–5]. This may be because of the retrospective nature of most of these reports and detection techniques. The purpose of this investigation was to prospectively evaluate patients undergoing pulmonary resection in an effort to determine the incidence of and predictors for the development of postoperative supraventricular dysrhythmias. Specifically we wished to test the following hypothesis: The incidence of postoperative supraventricular dysrhythmias is dependent on the magnitude of pulmonary resection. Our preinvestigation bias was that the incidence of supraventricular dysrhythmias increased progressively in patients undergoing pulmonary wedge resection, lobectomy, bilobectomy, or pneumonectomy.

	Materials and methods

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This research project was approved by the University of Missouri Institutional Review Board of Research Involving Human Subjects. Patients undergoing elective thoracotomy for probable pulmonary resection were identified and informed written consent for participation in this project was obtained. Twenty-four-hour Holter monitoring was obtained prior to scheduled thoracotomy, for an additional 24 hours beginning immediately after the operative procedure and on the second postoperative day. The three Holter recordings were reviewed by a senior cardiologist (B.M.P.) who was blinded to the extent of pulmonary resection and to perioperative clinical data. A research team dedicated to this project collected pre- and postoperative clinical and physiologic variables that might predict postoperative supraventricular dysrhythmias. These data were recorded in a patient database registry (Axis Clinical Software, Inc, Portland, OR). In addition to Holter monitoring, patients had continuous electrocardiogram (ECG) monitoring in the intensive care unit and in our postoperative step-down unit until the time of dismissal from the hospital. Premature atrial contractions (PAC) and sinus dysrhythmias were excluded from analysis. All other incidences of supraventricular dysrhythmia and whether pharmacologic treatment was applied were recorded.

All pulmonary resections were performed by thoracotomy with no attempt to standardize the surgical approach. There were no "radical" pneumonectomies performed in this series.

Ninety-seven patients had three 24-hour Holter monitor recordings as was the design of the investigation. Nineteen missed or had a malfunction of Holter monitoring during one of the three sampling times. Data were analyzed using only Holter findings with 97 patients, Holter plus continuous ECG findings in 116 patients, and only events requiring pharmacologic therapy in 116 patients. All methods resulted in the same conclusions regarding predictors for supraventricular dysrhythmia. The data for combined Holter and ECG occurrences in 116 patients will be presented.

	Statistical analysis

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Data are presented as mean ± standard deviation, unless otherwise indicated. Continuous data were analyzed using independent Student’s t tests when two sets were compared, or one-way analysis of variance for comparison of three or more sets. When normality or equal variance tests failed, an appropriate nonparametric alternative was applied. Categorical data were analyzed using ² analysis or Fisher’s exact test (for data sets with one or more cells 5). In all instances, p < 0.05 was considered significant.

	Results

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The study comprised 116 patients whose age ranged from 20 to 80 years (mean 59.8 years). There were 77 men and 39 women. Twenty-six patients underwent pneumonectomy, 7 bilobectomy, 47 lobectomy, and 36 wedge resection.

Twenty-six (22.4%) of the 116 patients developed supraventricular dysrhythmias. One patient developed atrial flutter, 3 atrial flutter/fibrillation, and 22 atrial fibrillation. The incidence of supraventricular dysrhythmia in patients having wedge resection, lobectomy, bilobectomy, or pneumonectomy was 13.8%, 17.0%, 14.3%, or 46.1%, respectively (p < 0.005 pneumonectomy versus others). Twenty-two of the 26 patients who developed postoperative supraventricular dysrhythmias required pharmacologic management, 8 or 31% of patients undergoing pneumonectomy and 14 or 16% of other patients.

The supraventricular dysrhythmias lasted from less than 1 day to 7 days with an average of 2.5 days. Figure 1 schematically displays all 26 patients who had a dysrhythmia postoperatively and the days when the dysrhythmia was present. The line graph connects the days of onset for the dysrhythmias.

View larger version (21K): [in this window] [in a new window]   Fig 1. A schematic display of days when dysrhythmia was present in the 26 patients who developed dysrhythmia following pulmonary resection. The line graph connects the day of onset of the dysrhythmia.

View larger version (12K): [in this window] [in a new window]   Fig 2. The percent of patient population who experienced the initial onset of supraventricular dysrhythmia on the various days postoperatively.

View larger version (15K): [in this window] [in a new window]   Fig 3. The day of onset of supraventricular dysrhythmia in the 26 patients having pneumonectomy and the 90 patients having a lesser resection.

View larger version (17K): [in this window] [in a new window]   Fig 4. The presence of supraventricular dysrhythmia among the 26 patients experiencing dysrhythmias on each of the postoperative days.

	Comment

Top Abstract Introduction Materials and methods Statistical analysis Results Comment Conclusions References

 
Cardiac dysrhythmias after thoracotomy for pulmonary resection have been well recognized and reported [2, 4, 6]. The majority of reports in the literature are retrospective with the incidence of dysrhythmia determined by chart review with its inherent lack of sensitivity. The reported incidence of dysrhythmia after thoracotomy also varies in part because of the lack of uniformity of definition of dysrhythmia and methods of detection. In this investigation we purposefully excluded sinus tachycardia often related to presence of pain or intravascular volume depletion, as well as PACs and bradydysrhythmias, neither of which required treatment clinically. Despite this restricted definition, 22.4% of patients developed supraventricular dysrhythmias as recorded by prospective Holter monitoring and continuous ECG analysis. All but 1 patient with supraventricular dysrhythmia had atrial fibrillation, which is acknowledged to be the principal dysrhythmia after thoracotomy [2, 7]. In a retrospective analysis, it is likely that our incidence of dysrhythmias would have been 18%, as 21 patients were treated for supraventricular dysrhythmias on the basis of ECG monitoring alone.

Our investigation was designed to include Holter monitoring preoperatively, intraoperatively, and on the second postoperative day. Preoperative Holter monitoring was selected for several reasons; if patients had preexisting supraventricular dysrhythmias that were first documented by postoperative continuous ECG monitoring, this incidence would not have been secondary to the operative procedure. Also, we had hoped that preoperative Holter monitoring recordings might serve as a useful selective screening tool to determine which patients would develop postoperative dysrhythmias. Specifically, we anticipated that multiple PACs on preoperative Holter records would translate to an increased incidence of atrial fibrillation or flutter after thoracotomy. This was proved untrue in that 16 (16.5%) of 97 patients were shown on preoperative Holter monitoring to have multiple PACs. None of these patients developed postoperative atrial fibrillation or flutter. Two (2.1%) of 97 patients had intermittent atrial fibrillation on preoperative Holter monitoring, and both did have intermittent atrial fibrillation postoperatively.

We chose to perform Holter monitoring on the day of surgery. Ritchie and colleagues [8] reported that the most common time for supraventricular dysrhythmias is during the initial 24 hours after thoracotomy. None of 116 patients in our series monitored by Holter recording and continuous ECG monitoring had onset of supraventricular dysrhythmia during the first 24 hours after thoracotomy.

Numerous authors have suggested that the time of peak onset of development of postoperative dysrhythmias is during the second postoperative day, prompting us to choose this day for continuous Holter monitoring [2, 4]. Overall, we found an equal incidence of supraventricular dysrhythmia onset on postoperative days 2 and 3. Those patients having pneumonectomy had their peak incidence of onset of dysrhythmia on the second postoperative day.

Significantly, 85% of all patients who developed postoperative supraventricular dysrhythmias did so during the first 3 postoperative days. In this series only 1 patient (< 1%) developed new onset of supraventricular dysrhythmias after the fifth postoperative day. This has significant relevance as clinical pathways and hospital dismissal strategies are developed for patients undergoing thoracotomy.

Of those patients experiencing supraventricular dysrhythmias, 27% will continue to have dysrhythmias on the sixth postoperative day (Fig 4).

The hospital stay was similar in this series of patients with or without dysrhythmias and no mortality was directly attributable to dysrhythmia. Others have shown mortality associated with dysrhythmia after thoracotomy [4]. Recently, Amar and colleagues [9] have made the observation that early supraventricular dysrhythmias after resection of non–small cell lung cancer is associated with poor long-term survival, although this finding remains to be confirmed by others.

Previously stated risk factors for the development of supraventricular dysrhythmia after pulmonary resection include malignant disease [3], sex [3], preoperative pulmonary function tests [6] increasing age [2], side of procedure [10], and extent of resection [2, 5]. In our series, 20 patients with benign disease had an incidence of supraventricular dysrhythmia of 11% and 96 patients with malignant disease had an incidence of 25% (p = 0.33). Some reviews might suggest a greater incidence of supraventricular dysrhythmias with malignant disease because more patients subjected to pneumonectomy have malignant disease and supraventricular dysrhythmias are more common with pneumonectomy.

Overall, sex was not found to be a predictor for development of supraventricular tachycardia after lung resection. However, men undergoing lobectomy had a 38% incidence of supraventricular dysrhythmia compared with 4% of women p = 0.026 (see Table 3).

We were unable to show a correlation between pre- and postoperative arterial blood gas values and pulmonary function tests with the development of postoperative dysrhythmias. This is in agreement with some [4, 11]. A weakness of most studies including ours is that arterial blood gases are not always obtained at the time of onset of supraventricular dysrhythmias. We did not attempt to correlate or quantitate atelectasis with the development of dysrhythmia.

Most authors have shown an increasing incidence of supraventricular dysrhythmias with increasing age [4, 6]. As can be seen from Table 4, in this series, older patients had a greater incidence of supraventricular dysrhythmias. This finding is largely the result of patients receiving lobectomy where the age of patients without dysrhythmias was an average of 58 years compared to 65 years in those with dysrhythmias (p = 0.038). The incidence of supraventricular dysrhythmias in patients older than 62 years, the median age of our series, was 18 (31%) of 58, compared with those younger 8 (14%) of 58, p = 0.045.

In contrast to the findings by Harpole and colleagues [10], we did not find that the side of resection, left or right, influenced the incidence of postoperative dysrhythmias (see Table 5).

Asamura and colleagues [2] and others [6] have shown a relationship between extent of pulmonary resection and the development of postoperative supraventricular dysrhythmias. We did not substantiate this finding in this prospective investigation where the incidence of dysrhythmias was similar with bilobectomy, lobectomy, and wedge resection. Pneumonectomy is associated with a significantly greater incidence of postoperative supraventricular dysrhythmia for reasons not elucidated in this investigation. Strategies for prevention of supraventricular dysrhythmias in this group have been successful [1, 12].

	Conclusions

Top Abstract Introduction Materials and methods Statistical analysis Results Comment Conclusions References

 
From this prospective investigation, we conclude that supraventricular dysrhythmia, specifically atrial fibrillation, is common after pulmonary resection. The occurrence of supraventricular dysrhythmia is not predictable and is not dependent on the magnitude of pulmonary resection. Patients having pneumonectomy in particular, and older male patients undergoing lobectomy, comprise a patient population at increased risk for postoperative atrial fibrillation. The peak incidence of onset of atrial fibrillation after pulmonary resection is during the second and third postoperative days. Supraventricular dysrhythmia may result in extended hospital stay but should rarely be a cause of mortality. Less than 1% of patients will develop supraventricular dysrhythmia after the fifth postoperative day, a fact which may influence clinical pathway hospital dismissal strategies. Preoperative Holter monitoring is not a helpful modality to select patients for prophylaxis against supraventricular dysrhythmias after thoracotomy.

	References

Top Abstract Introduction Materials and methods Statistical analysis Results Comment Conclusions References

 

1. Amar D., Burt M., Reinsel R.A., Leung D.H.Y. Relationship of early postoperative dysrhythmias and long-term outcome after resection of non-small cell lung cancer. Chest 1996;110:437-439.[Abstract/Free Full Text]
2. Asamura H., Naruke T., Tsuchiya R., Goya T., Kondo H., Suemasu K. What are the risk factors for arrhythmias after thoracic operations? A retrospective multivariate analysis of 267 consecutive thoracic operations. J Thorac Cardiovasc Surg 1993;106:1104-1110.[Abstract]
3. Keagy B.A., Schorlemmer G.R., Murray G.F., Lucas C.L., Wilcox B.R. Elective pulmonary lobectomy: factors associated with morbidity and operative mortality. Ann Thorac Surg 1985;40:349-352.[Abstract]
4. Von Knorring J., Lepantalo M., Lindgren L., Lindfors O. Cardiac arrhythmias and myocardial ischemia after thoracotomy for lung cancer. Ann Thorac Surg 1989;48:33-37.[Abstract]
5. Breyer R.H., Zippe C., Pharr W.F., Jensik R.J., Kittle C.F., Faber L.P. Thoracotomy in patients over age seventy years. J Thorac Cardiovasc Surg 1981;81:187-193.[Abstract]
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7. Wahi R., McMurtrey M.J., DeCaro L.F., et al. Determinants of perioperative morbidity and mortality after pneumonectomy. Ann Thorac Surg 1989;48:33-37.
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9. Amar D., Roistacher N., Burt M.E., et al. Effects of diltiazem versus digoxin on dysrhythmias and cardiac function after pneumonectomy. Ann Thorac Surg 1997;63:1374-1381.[Abstract/Free Full Text]
10. Harpole D.H., Jr, Liptay M.J., DeCamp M.M., Jr, Mentzer S.J., Swanson S.J., Sugarbaker D.J. Prospective analysis of pneumonectomy: risk factors for major morbidity and cardiac dysrhythmias. Ann Thorac Surg 1996;61:977-982.[Abstract/Free Full Text]
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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jack J. Curtis Joseph T. Walls Todd L. Demmy Richard A. Schmaltz Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Curtis, J. J. Articles by Schmaltz, R. A. Search for Related Content PubMed PubMed Citation Articles by Curtis, J. J. Articles by Schmaltz, R. A.