Unilateral Postoperative Pulmonary Edema After Minimally Invasive Cardiac Surgical Procedures: A Case-Control Study

摘要

OutcomesOperative ConductStatistical AnalysisAppendixReferencesUnilateral postoperative pulmonary edema is an underreported adverse event after a minimally invasive cardiac surgical procedure that combines right minithoracotomy with cardiopulmonary bypass. We sought to characterize its incidence, risk factors, and morbidity.MethodsWe conducted a retrospective case-control study of all cardiac surgical procedures that combined right-sided minithoracotomy with cardiopulmonary bypass at our institution over 8 consecutive years. Unilateral postoperative pulmonary edema was defined on the chest radiograph taken on the first postoperative day as relatively increased opacification of the right versus left hemithorax involving at least 20% of the hemithorax, not better explained by atelectasis. Baseline characteristics, potential risk factors, and outcomes were subject to univariable and multivariable analysis.ResultsRadiographs were available for 277 of 278 patients; of those, 68 (25%) met our definition of unilateral postoperative pulmonary edema. Patients with unilateral postoperative pulmonary edema had higher mortality and were more likely to have a lower postoperative PaO2/FIO2 ratio, to require vasoactive medications and mechanical ventilation for longer than 24 hours, and to have longer lengths of stay in the intensive care unit and the hospital. Unilateral postoperative pulmonary edema was independently associated with chronic obstructive pulmonary disease (odds ratio [OR] 4.79; 95% confidence interval [CI] 1.28 to 18.0; p?= 0.02); pulmonary hypertension, right-ventricular dysfunction, or both (OR 2.92; 95% CI 1.41 to 6.03; p?= 0.004); and increasing cardiopulmonary bypass time (OR 1.019; 95% CI 1.011 to 1.027 per additional minute; p <0.001).ConclusionsUnilateral postoperative pulmonary edema after minimally invasive cardiac surgical procedures is common, carries significant morbidity, and has identifiable risk factors. Further research is needed to enable a better understanding of the pathophysiology and clinical implications of unilateral postoperative pulmonary edema.CTSNet classification:11Minimally invasive cardiac surgical procedures often use a right minithoracotomy approach, one-lung ventilation, and cardiopulmonary bypass (CPB) through cannulation of peripheral vessels, typically the femoral artery or vein and the superior vena cava (SVC). Increased radiographic opacification of the right versus the left lung in the immediate postoperative period has been observed in several patients undergoing right minithoracotomy?for minimally invasive cardiac surgical procedures at our institution. Several of these patients?experienced significant adverse events. The opacification we have observed is phenotypically similar to reexpansion pulmonary edema, a rare adverse event after rapid lung reexpansion (Fig 1Fig 1).Fig 1Serial chest radiographs of a 67-year-old patient with moderate chronic obstructive pulmonary disease, significant pulmonary hypertension (right ventricular systolic pressure: 76/22 mm Hg), and obesity who underwent a minimally invasive mitral valve repair for Barlow’s disease. He experienced acute, unilateral, postoperative pulmonary edema shortly after returning to the intensive care unit. The serial chest radiographs demonstrate significant right lung opacification between the first and third postoperative days, with interval resolution thereafter. (Preop?= preoperative; POD?= postoperative day.)View Large Image | Download PowerPoint SlideReexpansion pulmonary edema most commonly occurs after decompression of significant pneumothoraces or rapid tube thoracostomy drainage of large, chronic pleural effusions [