INTRODUCTION: Ventilatory efficiency (VE/VCO2 slope) has been shown superior to peak oxygen consumption (VO2) for prediction of post-operative pulmonary complications in patients undergoing thoracotomy. VE/VCO2 slope is determined by ventilatory drive and ventilation/perfusion mismatch whereas VO2 is related to cardiac output and arteriovenous oxygen difference. We hypothesized pre-operative VO2 predicts post-operative cardiovascular complications in patients undergoing lung resection. METHODS: Lung resection candidates from a published study were evaluated by post-hoc analysis. All of the patients underwent preoperative cardiopulmonary exercise testing. Post-operative cardiovascular complications were assessed during the first 30 post-operative days or hospital stay. One-way analysis of variance or the Kruskal-Wallis test, and multivariate logistic regression were used for statistical analysis and data summarized as median (IQR). RESULTS: Of 353 subjects, 30 (9%) developed pulmonary complications only (excluded from further analysis), while 78 subjects (22%) developed cardiovascular complications and were divided into two groups for analysis: cardiovascular only (n = 49) and cardiovascular with pulmonary complications (n = 29). Compared to patients without complications (n = 245), peak VO2 was significantly lower in the cardiovascular with pulmonary complications group [19.9 ml/kg/min (16.5-25) vs. 16.3 ml/kg/min (15-20.3); P<0.01] but not in the cardiovascular only complications group [19.9 ml/kg/min (16.5-25) vs 19.0 ml/kg/min (16-23.1); P = 0.18]. In contrast, VE/VCO2 slope was significantly higher in both cardiovascular only [29 (25-33) vs. 31 (27-37); P = 0.05] and cardiovascular with pulmonary complication groups [29 (25-33) vs. 37 (34-42); P<0.01)]. Logistic regression analysis showed VE/VCO2 slope [OR = 1.06; 95%CI (1.01-1.11); P = 0.01; AUC = 0.74], but not peak VO2 to be independently associated with post-operative cardiovascular complications. CONCLUSION: VE/VCO2 slope is superior to peak VO2 for prediction of post-operative cardiovascular complications in lung resection candidates.

Department of Anesthesiology and Intensive Care St Anne's University Hospital Brno Brno Czech Republic

Department of Cardiovascular Diseases Mayo Clinic Rochester MN United States of America

Department of Respiratory Diseases University Hospital Brno Czech Republic

Department of Sports Medicine and Rehabilitation St Anne's University Hospital Brno

Faculty of Medicine Masaryk University Brno Czech Republic

Institute of Biostatistics and Analyses Ltd Brno Czech Republic

International Clinical Research Center St Anne's University Hospital Brno Brno Czech Republic

Zobrazit více v PubMed

Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST. 2013. May 1;143(5):e166S–e190S. doi: 10.1378/chest.12-2395 PubMed DOI

Brunelli A, Charloux A, Bolliger CT, Rocco G, Sculier JP, Varela G, et al.. ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy). European Respiratory Journal. 2009. Jul 1;34(1):17–41. doi: 10.1183/09031936.00184308 PubMed DOI

Begum SSS, Papagiannopoulos K, Falcoz PE, Decaluwe H, Salati M, Brunelli A. Outcome after video-assisted thoracoscopic surgery and open pulmonary lobectomy in patients with low VO 2 max: a case-matched analysis from the ESTS database †. European Journal of Cardio-Thoracic Surgery. 2016. Apr 1;49(4):1054–8. doi: 10.1093/ejcts/ezv378 PubMed DOI

Brunelli A, Belardinelli R, Pompili C, Xiumé F, Refai M, Salati M, et al.. Minute ventilation-to-carbon dioxide output (VE/VCO2) slope is the strongest predictor of respiratory complications and death after pulmonary resection. Ann Thorac Surg. 2012. Jun;93(6):1802–6. doi: 10.1016/j.athoracsur.2012.03.022 PubMed DOI

Shafiek H, Valera JL, Togores B, Torrecilla JA, Sauleda J, Cosío BG. Risk of postoperative complications in chronic obstructive lung diseases patients considered fit for lung cancer surgery: beyond oxygen consumption. Eur J Cardiothorac Surg. 2016. Oct;50(4):772–9. doi: 10.1093/ejcts/ezw104 PubMed DOI

Woods PR, Olson TP, Frantz RP, Johnson BD. Causes of breathing inefficiency during exercise in heart failure. J Card Fail. 2010. Oct;16(10):835–42. doi: 10.1016/j.cardfail.2010.05.003 PubMed DOI PMC

Beck KC, Randolph LN, Bailey KR, Wood CM, Snyder EM, Johnson BD. Relationship between cardiac output and oxygen consumption during upright cycle exercise in healthy humans. Journal of Applied Physiology. 2006. Nov 1;101(5):1474–80. doi: 10.1152/japplphysiol.00224.2006 PubMed DOI

Swank AM, Horton J, Fleg JL, Fonarow GC, Keteyian S, Goldberg L, et al.. Modest Increase in Peak VO2 Is Related to Better Clinical Outcomes in Chronic Heart Failure Patients. Circulation: Heart Failure. 2012. Sep 1;5(5):579–85. doi: 10.1161/CIRCHEARTFAILURE.111.965186 PubMed DOI PMC

Sellers D, Srinivas C, Djaiani G. Cardiovascular complications after non-cardiac surgery. Anaesthesia. 2018;73(S1):34–42. doi: 10.1111/anae.14138 PubMed DOI

Brat K, Homolka P, Merta Z, Chobola M, Heroutova M, Bratova M, et al.. Prediction of Postoperative Complications: Ventilatory Efficiency and Rest End-tidal Carbon Dioxide. The Annals of Thoracic Surgery [Internet]. 2022. Jan 21 [cited 2022 Jan 25]; Available from: https://www.sciencedirect.com/science/article/pii/S0003497522000601. doi: 10.1016/j.athoracsur.2021.11.073 PubMed DOI

Bennett-Guerrero E, Welsby I, Dunn TJ, Young LR, Wahl TA, Diers TL, et al.. The Use of a Postoperative Morbidity Survey to Evaluate Patients with Prolonged Hospitalization After Routine, Moderate-Risk, Elective Surgery. Anesthesia & Analgesia. 1999. Aug;89(2):514–9. doi: 10.1097/00000539-199908000-00050 PubMed DOI

Camm AJ, Kirchhof P, Lip GYH, Schotten U, Savelieva I, Ernst S, et al.. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Europace. 2010. Oct;12(10):1360–420. doi: 10.1093/europace/euq350 PubMed DOI

Mashour GA, Moore LE, Lele AV, Robicsek SA, Gelb AW. Perioperative care of patients at high risk for stroke during or after non-cardiac, non-neurologic surgery: consensus statement from the Society for Neuroscience in Anesthesiology and Critical Care*. J Neurosurg Anesthesiol. 2014. Oct;26(4):273–85. doi: 10.1097/ANA.0000000000000087 PubMed DOI

Torchio R, Guglielmo M, Giardino R, Ardissone F, Ciacco C, Gulotta C, et al.. Exercise ventilatory inefficiency and mortality in patients with chronic obstructive pulmonary disease undergoing surgery for non-small-cell lung cancer. Eur J Cardiothorac Surg. 2010. Jul;38(1):14–9. doi: 10.1016/j.ejcts.2010.01.032 PubMed DOI

Kazimierczak S, Rybicka A, Strauss J, Schram M, Kazimierczak A, Grochans E. External Validation Of The Surgical Mortality Probability Model (S-MPM) In Patients Undergoing Non-Cardiac Surgery. Ther Clin Risk Manag. 2019. Oct 4;15:1173–82. doi: 10.2147/TCRM.S212308 PubMed DOI PMC

Corrales-Medina VF, Musher DM, Wells GA, Chirinos JA, Chen L, Fine MJ. Cardiac Complications in Patients With Community-Acquired Pneumonia. Circulation. 2012. nor;125(6):773–81. doi: 10.1161/CIRCULATIONAHA.111.040766 PubMed DOI

Ferguson MK, Saha-Chaudhuri P, Mitchell JD, Varela G, Brunelli A. Prediction of major cardiovascular events after lung resection using a modified scoring system. Ann Thorac Surg. 2014. Apr;97(4):1135–40. doi: 10.1016/j.athoracsur.2013.12.032 PubMed DOI

Decker KD, Jorens PG, Schil PV. Cardiac complications after noncardiac thoracic surgery: an evidence-based current review. The Annals of Thoracic Surgery. 2003. Apr 1;75(4):1340–8. doi: 10.1016/s0003-4975(02)04824-5 PubMed DOI

Asamura H. Early complications. Cardiac complications. Chest Surg Clin N Am. 1999. Aug;9(3):527–41, vii–viii. PubMed

Liem VGB, Hoeks SE, Mol KHJM, Potters JW, Grüne F, Stolker RJ, et al.. Postoperative Hypotension after Noncardiac Surgery and the Association with Myocardial Injury. Anesthesiology. 2020. Sep 1;133(3):510–22. doi: 10.1097/ALN.0000000000003368 PubMed DOI

Smith H, Li H, Brandts-Longtin O, Yeung C, Maziak D, Gilbert S, et al.. External validity of a model to predict postoperative atrial fibrillation after thoracic surgery. European Journal of Cardio-Thoracic Surgery. 2020. May 1;57(5):874–80. doi: 10.1093/ejcts/ezz341 PubMed DOI

Jean RA, DeLuzio MR, Kraev AI, Wang G, Boffa DJ, Detterbeck FC, et al.. Analyzing Risk Factors for Morbidity and Mortality after Lung Resection for Lung Cancer Using the NSQIP Database. J Am Coll Surg. 2016. Jun;222(6):992–1000.e1. doi: 10.1016/j.jamcollsurg.2016.02.020 PubMed DOI

Salati M, Refai M, Pompili C, Xiumè F, Sabbatini A, Brunelli A. Major morbidity after lung resection: a comparison between the European Society of Thoracic Surgeons Database system and the Thoracic Morbidity and Mortality system. J Thorac Dis. 2013. Jun;5(3):217–22. doi: 10.3978/j.issn.2072-1439.2013.05.03 PubMed DOI PMC

Miyazaki T, Callister MEJ, Franks K, Dinesh P, Nagayasu T, Brunelli A. Minute ventilation-to-carbon dioxide slope is associated with postoperative survival after anatomical lung resection. Lung Cancer. 2018. Nov 1;125:218–22. doi: 10.1016/j.lungcan.2018.10.003 PubMed DOI

Brat K, Tothova Z, Merta Z, Taskova A, Homolka P, Vasakova M, et al.. Resting End-Tidal Carbon Dioxide Predicts Respiratory Complications in Patients Undergoing Thoracic Surgical Procedures. The Annals of Thoracic Surgery. 2016. Nov;102(5):1725–30. doi: 10.1016/j.athoracsur.2016.05.070 PubMed DOI

Arena R, Myers J, Aslam SS, Varughese EB, Peberdy MA. Peak VO2 and VE/VCO2 slope in patients with heart failure: a prognostic comparison. Am Heart J. 2004. Feb;147(2):354–60. doi: 10.1016/j.ahj.2003.07.014 PubMed DOI

Chua TP, Ponikowski P, Harrington D, Anker SD, Webb-Peploe K, Clark AL, et al.. Clinical correlates and prognostic significance of the ventilatory response to exercise in chronic heart failure. J Am Coll Cardiol. 1997. Jun;29(7):1585–90. doi: 10.1016/s0735-1097(97)00078-8 PubMed DOI

Kleber FX, Vietzke G, Wernecke KD, Bauer U, Opitz C, Wensel R, et al.. Impairment of ventilatory efficiency in heart failure: prognostic impact. Circulation. 2000. Jun 20;101(24):2803–9. doi: 10.1161/01.cir.101.24.2803 PubMed DOI

Nayor M, Xanthakis V, Tanguay M, Blodgett JB, Shah RV, Schoenike M, et al.. Clinical and Hemodynamic Associations and Prognostic Implications of Ventilatory Efficiency in Patients With Preserved Left Ventricular Systolic Function. Circulation: Heart Failure. 2020. May 1;13(5):e006729. doi: 10.1161/CIRCHEARTFAILURE.119.006729 PubMed DOI PMC

Chase PJ, Kenjale A, Cahalin LP, Arena R, Davis PG, Myers J, et al.. Effects of respiratory exchange ratio on the prognostic value of peak oxygen consumption and ventilatory efficiency in patients with systolic heart failure. JACC Heart Fail. 2013. Oct;1(5):427–32. doi: 10.1016/j.jchf.2013.05.008 PubMed DOI PMC

Gademan MGJ, Swenne CA, Verwey HF, van de Vooren H, Haest JCW, van Exel HJ, et al.. Exercise training increases oxygen uptake efficiency slope in chronic heart failure. European Journal of Cardiovascular Prevention & Rehabilitation. 2008. Apr 1;15(2):140–4. doi: 10.1097/HJR.0b013e3282ef19986 PubMed DOI

Causes of ventilatory inefficiency in lung resection candidates

Hyperoxemia post thoracic surgery - Does it matter?