Society for Translational Medicine Expert Consensus on the preoperative assessment of circulatory and cardiac functions and criteria for the assessment of risk factors in patients with lung cancer
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Society for Translational Medicine Expert Consensus on the preoperative assessment of circulatory and cardiac functions and criteria for the assessment of risk factors in patients with lung cancer

Deruo Liu1, Huanshun Wen1, Jie He2, Shugeng Gao2, Shanqing Li3, Lunxu Liu4, Jianxing He5,6, Yunchao Huang7, Shidong Xu8, Weimin Mao9, Qunyou Tan10, Chun Chen11, Xiaofei Li12, Zhu Zhang13, Gening Jiang14, Lin Xu15, Lanjun Zhang16, Jianhua Fu16, Hui Li17, Qun Wang18, Lijie Tan18, Danqing Li19, Qinghua Zhou20, Xiangning Fu21, Zhongmin Jiang22, Haiquan Chen23,24, Wentao Fang24, Xun Zhang25, Yin Li26, Ti Tong27, Zhentao Yu28, Yongyu Liu29, Xiuyi Zhi30, Tiansheng Yan31, Xingyi Zhang32, Alessandro Brunelli33, Michele Salati34, Kevin Phan35, Yasuhiro Hida36, Federico Venuta37, Jin-Ho Choi38, Kostas Papagiannopoulos33, Duc Ha39, Nuria Novoa40

1Department of Thoracic Surgery, China-Japan Friendship Hospital, Beijing 100029, China; 2Department of Thoracic Surgical Oncology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Cancer Center, Beijing 100021, China; 3Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medicine, Beijing 100730, China; 4Department of Cardiovascular and Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China; 5Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China; 6Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou 510120, China; 7Department of Thoracic and Cardiovascular Surgery, The Third Affiliated Hospital of Kunming Medical University (Yunnan Tumor Hospital), Kunming 650118, China; 8Department of Thoracic surgery, Harbin Medical University Cancer Hospital, Harbin 150086, China; 9Department of Thoracic Surgery, Zhejiang Cancer Hospital, Hangzhou 310000, China; 10Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing 400042, China; 11Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China; 12Department of Thoracic Surgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an 710038, China; 13Department of Thoracic Surgery, First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China; 14Department of Thoracic Surgery, Shanghai Pulmonary Hospital of Tongji University, Shanghai 200433, China; 15Department of Thoracic Surgery, Nanjing Medical University Affiliated Cancer Hospital, Jiangsu Key Laboratory of Molecular and Translational Cancer Research, Cancer Institute of Jiangsu Province, Nanjing 210009, China; 16Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou 510060, China; 17Department of Thoracic Surgery, Beijing Chaoyang Hospital, Beijing 100020, China; 18Department of Thoracic Surgery, Zhongshan Hospital of Fudan University, Shanghai 200032, China; 19Department of Thoracic Surgery, Peking Union Medical College Hospital, Beijing 100730, China; 20Department of Lung Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, China; 21Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; 22Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan 250014, China; 23Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200000, China; 24Department of Thoracic Surgery, Shanghai Chest Hospital, Jiao Tong University, Shanghai 200336, China; 25Tianjin Chest Hospital, Tianjin 300051, China; 26Department of Thoracic Surgery, Henan Cancer Hospital, Zhengzhou 450008, China; 27Department of Thoracic Surgery, Second Hospital of Jilin University, Changchun 130041, China; 28Department of Esophageal Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China; 29Department of Thoracic Surgery, Liaoning Cancer Hospital and Institute, Shenyang 110042, China; 30Department of Thoracic Surgery, Xuanwu Hospital of Capital Medical University, Beijing 100053, China; 31Department of Thoracic Surgery, Peking University Third Hospital, Beijing, China; 32Department of Thoracic Surgery, The Second Hospital of Jilin University, Changchun 130041, China; 33Department Thoracic Surgery, St. James’s University Hospital, Leeds, LS9 7TF, UK; 34University of Ancona, School of Medicine, Ancona, Italy; 35The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia; 36Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine, Hokkaido University, Sapporo, Japan; 37Department of Thoracic Surgery, Policlinico Umberto I, University of Rome Sapienza, Rome, Italy; 38The Division of Cardiology,Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 39Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA 92037-7381, USA; 40Servicio de Cirugía Torácica, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain

Correspondence to: Jie He, MD, PhD; Shugeng Gao, MD, PhD. Department of Thoracic Surgical Oncology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Cancer Center, Beijing 100021, China. Email: hejie@cicams.ac.cn; gaoshugeng@vip.sina.com.

Submitted Mar 31, 2018. Accepted for publication Aug 07, 2018.

doi: 10.21037/jtd.2018.08.91


Part I: basic contents of the project

Project name: methods for the preoperative assessment of cardiovascular functions and criteria for the assessment of risk factors in patients with lung cancer.

Research purpose and contents: the purpose of the study is to investigate the impact of preoperative cardiovascular evaluation on the perioperative cardiovascular risk of patients undergoing surgery for lung cancer. The main aspects of the study incorporate cardiovascular-related assessments on the safety and outcomes of lung cancer surgery.

Main research questions: preoperative assessments of coronary heart disease, heart failure, cardiomyopathy, cardiac valvular disease, cardiac rhythm and conduction disorders, pulmonary vascular disease, and congenital heart disease.


Part II: background and current status of the project

Current research status of the project: perioperative cardiovascular events are one of major complications following lung cancer surgery. Myocardial infarction is the second most common cause of perioperative death after pulmonary resections. Because lung cancer surgery carries a significant hemodynamic burden, preoperative assessment of cardiac function is a critical issue. However, current preoperative examinations of lung cancer focused on pulmonary functions, and research on cardiac function requires further extensive investigation. The preoperative specification and inspection indicators are mainly derived from general findings of non-cardiac surgery but are not specific to lung cancer surgery.

Main research significance of the project: the project aims to better assess perioperative cardiovascular risks in patients with undergoing lung cancer surgery and to provide a reliable reference for perioperative safety.


Preoperative cardiac function tests

  • A routine 12-lead electrocardiogram should be performed prior to lung cancer surgery irrespective of the presence of known cardiovascular disease (1-4). (Level of evidence: B).
  • Patients with unexplained dyspnea or suspected to have heart failure should be screened by echocardiography; echocardiography should also be performed in patients with a history of heart failure who are currently in a stable condition and who have not had an assessment within the last 12 months (5). (Level of evidence: C).
  • Exercise stress testing is not routinely required. However, patients with risk factors for myocardial ischemia with poor functional capacity (<4 metabolic equivalents (METs)) or lack of functional capacity assessment should undergo exercise stress testing (6). (Level of evidence: C).
  • Patients with risk factors but asymptomatic should undergo cardiopulmonary exercise testing, such as the six-minute walk test or stair climb test (7-12). (Level of evidence: B).
  • Preoperative coronary angiography is not routinely required (13). However, a coronary angiography should be performed in patients with known coronary heart disease. (Level of evidence: C).

Risk factors

  • Unstable angina pectoris can substantially increase postoperative morbidity and mortality in patients with cardiovascular disease (14). Therefore, patients with coronary heart disease should undergo coronary angiography. If indications for an intervention are established, coronary stents or heart bypass surgery should be taken into consideration. (Level of evidence: C).
  • Patients with a myocardial infarction within two months from surgery are not suitable for lung cancer surgery. One study (15) has showed that the interval length between surgery and preoperative myocardial infarction is directly proportional to the probability of postoperative myocardial infarction (0 to 30 days =32.8%, 31 to 60 days =18.7%, 61 to 90 days =8.4%, and 91 to 180 days =5.9%) and postoperative mortality (0 to 30 days =14.2%, 31 to 60 days =11.5%, 61 to 90 days =10.5%, and 91 to 180 days =9.9%). (Level of evidence: B).
  • The degree of attention paid to the preoperative assessment and control of heart failure should be improved to the same level as such for coronary artery disease. One study (16) showed that patients with non-ischemic heart failure, ischemic heart failure, and atrial fibrillation exhibited significantly higher postoperative 30-day mortality than those with coronary heart disease (99.3% vs. 9.2% vs. 6.4% vs. 2.9%). This finding indicates that although sufficient attention is paid to coronary artery disease such is not evident in patients with heart failure prior to surgery. Therefore, an echocardiography should be performed in patients with heart failure to assess their cardiac functions. Patients with a left ventricular ejection fraction below 40% deserve careful consideration for surgery due to significantly increased risk of death (17). (Level of evidence: B).
  • Cardiomyopathy can increase the incidence of perioperative cardiovascular events. There is a need to assess preoperative cardiac functions in detail and to pay attention to perioperative management (18,19). (Level of evidence: C).
  • Moderate to severe aortic stenosis can increase the 30-day mortality and incidence of 90-day cardiovascular events. Hemodynamic monitoring is required even for asymptomatic patients (20) (Level of evidence: B). Percutaneous valve implantation may improve cardiac functions and achieve effects similar to valve surgery (21,22). However, there is lack of data confirming whether subsequent non-cardiovascular surgery is safe following this approach. (Level of evidence: C).
  • Patients with surgical indications for mitral stenosis should undergo relevant preoperative therapy (23). Intraoperative and perioperative hemodynamic monitoring should be performed in patients with mitral stenosis and patients who have undergone mitral valve surgery. (Level of evidence: C).
  • Aortic and mitral regurgitation can increase the risk of cardiovascular complications (24,25). Hemodynamic monitoring should be performed for patients with severe aortic or mitral regurgitation. (Level of evidence: C).
  • Patients with stable atrial fibrillation prior to surgery require only routine anticoagulation and have no need of additional medication or special interventions prior to lung cancer surgery. Although ventricular arrhythmia is a risk factor of postoperative and intraoperative arrhythmia, it does not increase the risk of myocardial infarction and cardiac death. Therefore, cardiology experts should be consulted to jointly assess whether the cardiac function requires further examination (26,27). (Level of evidence: C).

Part IV: problems still open

  • What is the optimal operation time interval in patients with myocardial infarction?
  • What is the acceptable lower left ventricular ejection fraction?
  • Can non-cardiac surgery research findings completely guide lung cancer surgery?

Part V: main protocol of future research

  • To study risks associated with surgery for lung cancer in patients who have undergone surgery for myocardial infarction;
  • To study the risks associated with lung cancer surgery in patients with heart failure and the importance of pre-operative volume status assessment and perioperative fluid management in these patients;
  • To study the effects of surgical approaches to major lung resection surgery on perioperative cardiovascular outcomes.

Acknowledgements

The authors gratefully acknowledge the manuscript review by Dr. Guangliang Qiang from Department of Thoracic Surgery, China-Japan Friendship Hospital, Beijing, China.


Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.


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Cite this article as: Liu D, Wen H, He J, Gao S, Li S, Liu L, He J, Huang Y, Xu S, Mao W, Tan Q, Chen C, Li X, Zhang Z, Jiang G, Xu L, Zhang L, Fu J, Li H, Wang Q, Tan L, Li D, Zhou Q, Fu X, Jiang Z, Chen H, Fang W, Zhang X, Li Y, Tong T, Yu Z, Liu Y, Zhi X, Yan T, Zhang X, Brunelli A, Salati M, Phan K, Hida Y, Venuta F, Choi JH, Papagiannopoulos K, Ha D, Novoa N. Society for Translational Medicine Expert Consensus on the preoperative assessment of circulatory and cardiac functions and criteria for the assessment of risk factors in patients with lung cancer. J Thorac Dis 2018;10(9):5545-5549. doi: 10.21037/jtd.2018.08.91