Unilateral Pulmonary Artery Occlusion Test Research Articles

Unilateral pulmonary artery pre-operative occlusion test: technical feasibility and safety prior to pneumonectomy or pleuropneumonectomy for malignancy.

The aim of the present study was to assess the technical feasibility and safety of the unilateral pulmonary artery occlusion (UPAO) test in pre-operative evaluation of pneumonectomy or pleuropneumonectomy for lung or pleural tumours. The UPAO test was performed on 91 patients who were scheduled to undergo or were being considered for pneumonectomy or pleuropneumonectomy between June 2003 and July 2016. There were 74 males and 17 females, with a median age of 65 years (range, 23-80). The technical success rate, procedure time and complication rate were evaluated. Technical success was defined as completion of the UPAO test. The diagnoses of the 91 patients were as follows: lung cancer in 63, malignant pleural mesothelioma in 21, thymoma in 5, lung metastasis in 1 and lung carcinoid in 1. The UPAO test was performed successfully on 88 out of 91 patients (technical success rate: 97%). The median procedure time was 57 min (range, 34-120). Cardiac arrest due to migration of the balloon catheter to the pulmonary trunk occurred in 1 patient (complication rate: 1.1%). The UPAO test in pre-operative evaluation of pneumonectomy or pleuropneumonectomy for lung or pleural tumours appears to be technically feasible. However, it needs to be performed with care in order to avoid severe complications. Advances in knowledge: The UPAO test can be safely performed and is helpful in evaluating patients for pneumonectomy or pleuropneumonectomy.

Extension of functional limitation for surgery of lung cancer by unilateral pulmonary arterial occlusion test

We performed unilateral pulmonary arterial occlusion test to determine the indication for lung resection functionally, and investigated 32 cases whose total pulmonary vascular resistance was over 700 dyne.sec.cm-5/M2. Thirteen out of 32 cases underwent surgery. There was no difference in lung function tests between surgical and non-surgical cases. Nine out of 12 cases whose pulmonary vascular resistance was less than 800 dyne by unilateral pulmonary arterial occlusion test underwent surgery, and none of these cases died within 3 months after surgery. In non-surgical cases, two were aged patients and one had chronic renal failure. Four out of 20 cases whose total pulmonary vascular resistance was over 800 dyne underwent surgery. Two cases that underwent surgery died within 3 months after surgery. These results suggest that the functional limitation of lung resection can be extended from 700 dyne.sec.cm-5/M2 to 800 dyne.sec.cm-5/M2 total pulmonary vascular resistance by application of unilateral pulmonary arterial occlusion test.

Changes in right ventricular function with unilateral pulmonary artery occlusion test for pre-operative evaluation prior to lung resection

We measured the right ventricular ejection fraction (RVEF) before and during unilateral pulmonary artery occlusion test (UPAO) by thermodilution method. We also measured the right ventricular end-diastolic volume index (RVEDVI), right ventricular end-systolic volume index (RVESVI), and right ventricular stroke volume index (RVSVI). RVEF and RVSVI were significantly decreased by UPAO (p less than 0.05), but there were no obvious changes in RVEDVI and RVESVI. Some cases showed only a small decrease in RVEF by UPAO, even though their total pulmonary vascular resistance indices were over 700 dyne.sec.cm-5/m2 during UPAO. On the other hand, some cases had a decreased in RVEF of more than 10% by UPAO, even though their total pulmonary vascular resistance indices were under 400 dyne.sec.cm-5/m2 during UPAO. We consider that it is important to measure right ventricular functions such as RVEF together with pulmonary vascular hemodynamics in the pre-operative evaluation of cases of lung resection.

Changes in right ventricular hemodynamic function by unilateral pulmonary arterial occlusion test

We performed unilateral pulmonary arterial occlusion test (UPAO) for the preoperative evaluation of lung function in patients undergoing lung resection. In this test, the main pulmonary artery of either side is occluded to simulate postoperative functional status. In order to evaluate the right ventricular hemodynamic function, we measured right ventricular ejection fraction (RVEF) and right ventricular end-diastolic volume index (RVEDVI) throughout UPAO by thermodilution method. We investigated the relationships between changes in right ventricular hemodynamic function and postoperative complications related to cardiac functions, namely arrhythmias or heart failure. Thirty-four patients without heart disease prior to lung resection were examined by UPAO, and RVEF and RVEDVI were measured. Analyses demonstrated that changes in RVEF were inversely correlated with changes in RVEDVI. In 6 cases, RVEDVI increased from control by over 20% during UPAO. All of these patients had postoperative cardiac complications. The hypothetical ventricular function curves showed a large increase in RVEDVI relative to right ventricular stroke work index (RVSWI), suggesting a decrease in right ventricular function. In conclusion, these results suggest that changes in RVEDVI during UPAO may predict postoperative cardiac complications in patients undergoing pulmonary resection.

Correlation between slopes of pulmonary blood flow-driving pressure curve and routine pulmonary function

In 91 preoperative cases of lung cancer, an attempt was made to correlate the slopes of pulmonary blood flow-driving pressure curve (delta DP/delta CI), as constructed from unilateral pulmonary arterial occlusion (UPAO) test values and pulmonary blood flow fraction values as measured by scintigraphy, with total pulmonary vascular resistance index (TPVRI) and pulmonary vascular resistance index (PVRI) and routine pulmonary function. FVC and FEV per unit body surface (BSA) were found to correlate, to same degree, with delta DP/delta CI, TPVRI and PVRI (p less than 0.05). delta DP/delta CI correlated significantly with FRC/BSA, whereas TPVRI and PVRI did not. 3) The inverse of the cardiac index (1/cardiac index) was shown to significantly correlate with TPVRI and PVRI (r = 0.64, 0.48), but poorly with delta DP/delta CI (r = 0.32). These results suggest that delta DP/delta CI might possibly provide a more useful quantitative index for the pulmonary vascular bed than TPVRI and PVRI.

Retrospective investigation of pulmonary resection in patients with high total pulmonary vascular resistance during preoperative unilateral pulmonary artery occlusion

The aim of this study was to evaluate the indications for pulmonary resection (lobectomy) in patients with increased total pulmonary vascular resistance (TPVR) during a preoperative unilateral pulmonary artery occlusion (UPAO) test. According to our previous report, the feasibility of performing lobectomy in patients with a high risk of cardiopulmonary complications is determined on the basis of the increase in TPVR after 15 min of obstruction during the UPAO test (occluded TPVR). A total of 19 high-risk [occluded TPVR > or =700 dynes/s/cm(-5)/m(2) (dynes)] patients who underwent lobectomy or pneumonectomy were studied and a detailed analysis of postoperative cardiopulmonary complications was performed. The subjects were divided into four groups based on the occluded TPVR (700-799 dynes, 800-899 dynes, 900-999 dynes, or > or =1000 dynes) to compare the incidence of postoperative complications. Two patients died after surgery. One of them had an occluded TPVR >1000 dynes and died 313 days after right upper lobectomy; the other had an occluded TPVR of 783 dynes and died 20 days after right pneumonectomy. Postoperative cardiopulmonary complications occurred in 6 of 19 patients (31.6%), and all three patients with an occluded TPVR > or =900 dynes developed cardiopulmonary complications. Limited surgery should be performed in patients with an occluded TPVR > or =900 dynes.

Bullectomy is beneficial in the pulmonary blood flow/driving pressure relationship in bullous emphysema patients.

Few physiological studies have been on pulmonary circulation, including the relationship between pulmonary blood flow and driving pressure, and viscosity changes arising from hematocrit changes before versus after lung volume reduction Surgery or bullectomy in emphysematous patients. We studied the relationship between pulmonary blood flow and driving pressure before and after bullectomy using a unilateral pulmonary artery occlusion test based on pulmonary blood flow fractions obtained by pulmonary blood flow scintigraphy in 7 patients with pulmonary emphysema associated with bullae. Among the 7 undergoing bullectomy, the pulmonary blood flow/driving pressure relationship decreased in 5 and was unchanged in 2. Of the 11 lungs treated by bullectomy, this relationship decreased in 8 lungs, but not 3 (p < 0.01). No significant difference was seen in oxygen partial pressure in arterial and mixed venous blood or hematocrit. We concluded that bullectomy shifted the pulmonary blood flow/driving pressure relationship downword in some cases with significant bullae.

Clinical assessment of unilateral pulmonary artery occlusion test with dobutamine infusion. Expansion of surgical indications in patients with primary lung cancer and impaired cardiopulmonary functions.

We evaluated the possibility of expanding indications for pulmonary resection based on an assessment of the pressure-flow relationship in pulmonary circulation. In 6 of 28 lung cancer patients whose total pulmonary vascular resistance index exceeded the threshold during unilateral pulmonary artery occlusion testing, we conducted unilateral pulmonary artery occlusion testing with dobutamine administration, followed by lung resection. We studied hemodynamics during testing and derived a new indication for pulmonary resection from the postoperative course. Cardiac output was 3.82 +/- 0.74 l/min before testing, 3.66 +/- 0.76 l/min during pulmonary artery occlusion testing, and 5.92 +/- 1.78 l/min during unilateral pulmonary artery occlusion testing with dobutamine infusion. The total pulmonary vascular resistance index was 890 +/- 350 dyne.sec.cm-5.m2 before testing, 1170 +/- 320 dyne.sec.cm-5.m2 during testing, and 800 +/- 160 dyne.sec.cm-5.m2 during testing with dobutamine infusion. Cardiac output increased (p = 0.014) during unilateral pulmonary artery occlusion testing with dobutamine infusion, and the total pulmonary vascular resistance index significantly decreased (p = 0.034). Of the 4 patients eligible for lobectomy, 2 underwent the procedure--one undergoing segmentectomy in which pulmonary metastasis was found during surgery and the other undergoing radiotherapy for cN2 disease with chest wall invasion. Of the 2 initially ineligible for lobectomy, one underwent partial pulmonary resection and the other underwent lobectomy because the total pulmonary vascular resistance index was less than 800 dyne.sec.cm-5.m2 during selective pulmonary artery occlusion testing with dobutamine infusion, indicating eligibility for lobectomy. No severe complications of cardiopulmonary function failure after surgery occurred in any of the 5 cases. Unilateral pulmonary artery occlusion testing with dobutamine infusion is useful in determining patient eligibility for pulmonary resection.

Functional evaluations for pulmonary resection for lung cancer in octogenarians. Investigation from postoperative complications.

We have reviewed the records of our twenty-four patients aged 80 years or older who underwent lung resections for bronchogenic carcinoma between 1983 and 1997 in our department. Eighteen patients were male and six were female. Adenocarcinoma was the histology in more than half of the cases (13 patients), along with 8 squamous cell carcinoma, 2 large cell carcinoma, and one small cell lung carcinoma. More than single lobectomy was performed in each patient. Unilateral pulmonary occlusion tests were employed in patients with impairment in pulmonary functions. Every patient, who underwent the unilateral pulmonary occlusion test, was certified that the total pulmonary vascular resistance index during unilateral pulmonary arterial occlusion test was less than 700 dyne.sec.cm-5.m2. Postoperative cardiovascular complications, such as paroxysmal atrial tachycardia, premature atrial contraction, premature ventricular contraction or atrial fibrillation, were seen in 10 patients. Postoperative respiratory complications, namely, sputa retention, retained secretions or atelectasis, were seen in 7 patients. The extent of dissection of mediastinal lymph node was not correlated to the postoperative pulmonary complications. However, the incidence of arrhythmias in the patients who received R2 mediastinal lymphnode dissection was much higher than in those who received R1 or R0 dissection. Complete blood counts and serum biochemical analysis performed at about three weeks after operations revealed leukocytosis and increases in levels of serum transaminase. These phenomena in leukocytosis and increases in the levels of serum transaminase in these patients were similar to those in younger patients. There was no operative death. We conclude that some patients over 80 years are candidates for lung resection after careful preoperative cardiopulmonary evaluation.

Oxygen Transport during Incremental Exercise Load as a Predictor of Operative Risk in Lung Cancer Patients

To evaluate functional parameters related to the morbidity and mortality after thoracotomy, exercise loading was applied in 31 lung cancer patients under right heart catheterization. The routine pulmonary function and predicted postoperative pulmonary function (ppo) parameters were also evaluated. Patients were grouped according to postoperative complications: no complications (group 1, n = 17), nonfatal complications (group 2, n = 10), and fatal complications (group 3, n = 4). In all the patients %VCppo was above 40 percent and in patients undergoing pneumonectomy, pulmonary artery mean pressure during the unilateral pulmonary artery occlusion test was below 25 mm Hg. FEV1 percent and MVV/BSA were statistically significant between groups 1 and 2 but were not between groups 1 and 3 or groups 2 and 3. The %FEV1 ppo was statistically significant between groups 1 and 2 and groups 1 and 3 but was not between groups 2 and 3. Thus, the routine pulmonary function and predicted postoperative lung function tests, although they are mandatory for screening patients who are at risk, did not definitely discriminate between patients experiencing nonfatal and fatal complications after thoracotomy. VO2/BSALa20, CILa20, O2D/BSALa20, and TPVRILa20 were statistically significant between groups 1 and 3 and groups 2 and 3: in all the group 3 patients, as well as three patients of group 1 and one of group 2, VO2/BSALa20 was below 350 ml/min/m2. On the other hand, O2D/BSALa20 was below 500 ml/min/m2 in all the group 3 patients, while it was above 560 ml/min/m2 in all patients in groups 1 and 2. O2D/BSALa20 was the only parameter that definitely discriminated between experiencing nonfatal and fatal complications. We conclude that in addition to the generally accepted functional guidelines, VO2/BSALa20 should be above 400 ml/min/m2 and O2D/BSALa20 should be above 500 ml/min/m2 in patients who will undergo thoracotomy.

Cardio-pulmonary function evaluated by selective pulmonary arterial occlusion test

We succesfully performed 3 repeat pulmonary resections for recurrent cancer in the contralateral lung, after evaluating cardio-pulmonary function by a unilateral pulmonary arterial occlusion test (UPAO) and a selective pulmonary arterial occlusion test (SPAO). UPAO revealed a marked decreases of cardio-pulmonary reserve capacity in the operated lung. However, SPAO revealed that the cardio-pulmonary reserve capacity in the residual lung tissue would be enough to compensate for the loss of pulmonary vasculature by the second pulmonary resction. Thus we conclude that SPAO is useful in the preoperative evaluation of patients with impaired cardio-pulmonary reserve capacity.

Combined surgery for lung cancer and giant emphysematous bulla : a case report

A 77-year-old male was admitted because of dyspnea and an abnormal chest X-ray. He had been followed for giant bulla in the left lung for 3 years. On admission, his chest roentgenogram revealed a giant bulla occupying one half of the left lung and a tumor shadow in the right upper lung field. Pulmonary function tests, including %VC, FEV 10 and unilateral pulmonary artery occlusion test, demonstrated the impaired left pulmonary function.Bronchial biopsy of the orifice of S1 a confirmed the diagnosis of well-differentiated squamous cell carcinoma. Simultaneous operation for bilateral lung disease was successfully performed a combination of Naclerio-Langer bullectomy with a stapling device, fibrin glue for the giant emphysematous bulla in the left lower lobe and right upper lobectomy for the lung cancer (t1n1m0 p-stage II) through a median sternotomy.Surgical indications and operative techniques for giant bulla and lung cancer are discussed.

Determination of the upper safety limit for lung resection

In lobectomy using animals, a stepwise gradual increase in the volume of lung resection is encountered by elevation of the pulmonary arterial pressure followed by reduction of the cardiac output, when lung resection exceeds a certain limit in volume.In a unilateral pulmonary arterial occlusion test, we compared the exercise-loaded cardiopulmonary function with the postoperative cardiopulmonary function.In consideration of the cardiopulmonary reserve capacity, the physiological safety limit of the lung resection was found to correspond to the total pulmonary vascular resistance of 700 dyne.sec.cm-5/m2 in the contralateral lung.We usually perform lung resection on lung cancer patients regardless of age, provided that they preserve cardiopulmonary function within the above limit.However, patients with this safety limit easily develop postoperative lung complication. The upliftment of the safety limit in lung resection is considered to depend on prevention of postoperative lung complication. This paper pointed out that a large number of resectable cases are included in lung cancer patients in whom lung resection is contraindicated for preservation of ventilatory function.

Hemodynamic Response in Lung Transplantation as a Model of Total Lung Denervation

As a means to approach the question regarding the exact effect of lung denervation, hemodynamic studies were carried out in 49 dogs which had undergone either unilateral or bilateral lung autotransplantation. In 14 chronically survived animals of 20 with unilateral lung reimplant, unilateral pulmonary artery occlusion test was carried out. In the 29 with either one-stage or two-stage bilateral lung reimplants, serial hemodynamic studies were performed along with histologic examinations of the transplanted lung at autopsy. In the chronic survivors with the bilateral transplants, rapid and continuing infusion of 3, 000 ml of plasma expander was performed within 10 min through intraatrial catheter and various hemodynamic values were measured simultaneously. The animals with one-stage bilateral lung reimplants showed a varying degree of pulmonary edema in both lungs in the early postoperative period, and some of them succumbed to respiratory failure with a gradual decease in PaO2 but the other animals recovered from these pathologic states within 10 postoperative days and survived chronically. Hemodynamics of those longterm survivors showed high pulmonary vascular resistance early after surgery but this value returned nearly to the preoperative level in a distant postoperative period. On occlusion of contralateral pulmonary artery in unilateral lung replantation an increase in pulmonary arterial pressure was invariably observed. Their relationship was steep and almost linear against a given increment of cardiac output when cardiac output vs. pulmonary arterial pressure was plotted in each animal. These facts suggest that transplant differs from the normal lung in tolerance of the vasculature in an event of an increase in pulmonary blood flow. In the plasma expander infusion test, the dog with bilateral lung autotransplants demonstrated that pulmonary arterial pressure showed a parallel and linear increase with an increase in cardiac output until lung transplant became edematous, while in the control animal total pulmonary vascular resistance decreased with an increment in pulmonary arterial pressure during the course of increasing cardiac output. It can be interpreted from these results that changes have occurred in mechanism of pulmonary circulation of the transplant; the transplanted lungs cannot vasodilate totally with an increase in blood flow.

1側肺動脈閉塞の肺循環に及ぼす影響第1篇 1側肺動脈閉塞の肺循環系血圧に及ぼす影響について

Twenty-one non-operated cases with pulmonary tuberculosis have been studied after their unilateral pulmonary artery had been temporarily occluded with a ballon catheter.The results obtained were as follows;1. Occlusion of the pulmonary artery results in a rise in proximal pulmonary artery pressure. When the non-occluded lung is slightly are not involved, the rise is scarcely observed.The involvement of 2/3 the non-occluded lung area on roentogenogram is a maximal limit for occlusion for fear of fatality.The blood pressure distal to occlusion immediately decreases nearly to wedge pressure level, and it shows a change from an arterial to a venous form.2. Minute ventilation and oxygen consumption show an increase following occlusion. The increase is more marked in Group A in which the pulmonary artery in the morbid lung is occluded than in Group B in which the pulmonary artery in the less morbid other lung. It is to be noted that even the occluded lung shows a slight consumption of oxygen and a slight production of carbon dioxide.Per cent vital capadity, per cent maximum breathing capacity, timed vital capacity, per one sec. and per cent vital capacity in the contralateral lung measured before occlusion decrease in far advanced cases under a mean pulmonary artery pressure of over 20 mmHg.3. A slight decrease is observed in arterial oxygen saturation as well as in oxygen content during occlusion. The decrease is more marked in Group B than in Group A. The carbon dioxide content in the arterial blood during occlusion slightly increases.The distal blood sample during pulmonary artery occlusion has a higher oxygen and lower carbon dioxide content than the systemic arterial blood sample.A-V oxygen difference, total pulmonary vascular resistance and right ventricular work for pressure show an increase during occlusion. The increase is more marked in Group B than Group A. Cardiac index during occlusion increases or decreases depending upon individal cases.4. Following occlusion the E C G findings have revealed that there occurs each one case of right bundle branch block and incomplete right bundle branch block among the 18 cases studied.It is suggested that pulmonary artery occlusion results in an increase of work load of the right heart.5. Unilateral pulmonary artery occlusion test seems to be required in deciding the indication for pulmonary resection especially for pneumonectomy, if the lesion is found in the contralateral lung, total per cent vital capacity is less than 60 % or vital capacity in the contralateral lung is less than 40%.