Interactive cardiovascular and thoracic surgery. 2008 Jul 9. [Epub ahead of print] [Link]

Neragi-Miandoab S, Winer S, Sugarbaker DJ.

New York Medical College, School of Medicine, New York, USA.


Extrapleural pneumonectomy (EPP) and pleurectomy are the surgical procedures for the treatment of pleural mesothelioma. However, EPP increases the risk for postoperative atrial fibrillation (AF) in this patient population, which might be partly explained by increase in right heart stress after EPP. We conducted a retrospective chart review of 130 patients who were treated for malignant pleural mesothelioma with either pleurectomy or EPP between 2001 and 2003 in a single institution. Risk factors for AF were evaluated with logistic regression and the postoperative AF events were evaluated. The absence of a history of cardiac arrhythmia was an inclusion criterion. Seventy patients (excluding the 3 patients with a prior history of AF) underwent EPP and 57 patients underwent pleurectomy. The mean ages were 60+/-11 and 63+/-13, and the male to female ratios were 50/20 and 44/13, respectively. Postoperative AF was observed in 45 patients with 36 (51%) of these cases occurring after EPP and 9 (17%) after pleurectomy (p<0.0001). There were no significant differences between the two treatment groups for gender, age, side of affected lung, preoperative heart rate and history of beta-blocker use, coronary heart disease, and chronic obstructive pulmonary disease. There were significant differences between the two groups for cancer histology (p=0.03) with the EPP group having a larger proportion of epithelial-type histology. Through logistic regression, EPP (OR=7.1, 95% CI: 2.9, 17.8) and age over 65 (OR=2.9, 95% CI: 1.2, 6.8) were found to be risk factors for AF. Abnormal cardiac structure and function were identified as important possible confounder, which could not be adequately evaluated due to missing data. Most of these patients had at least one additional expected risk factor for AF. EPP versus pleurectomy and age over 65 are risk factors for postoperative AF. The increased odds of having AF after EPP could be due to right heart stress caused by pneumonectomy. Increased right heart stress might not be sufficient to cause AF alone, but may be an important risk factor that warrants further investigation.

Keywords: Right heart stress; Extrapleural pneumonectomy; Pleurectomy; Atrial fibrillation.