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Pneumonectomy in the seventh decade in a patient with a congenital uncorrected ventricular septal defect

Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool, L14 3PE, UK

Received 19 December 2008; received in revised form 20 February 2009; accepted 16 March 2009

*Corresponding author. Tel.: +151 293 2456/2398; fax: +151 293 2254.

E-mail address: mike.poullis{at}lhch.nhs.uk (M. Poullis).

	Abstract

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
We describe the successful treatment of a patient in his seventh decade with a congenital uncorrected ventricular septal defect (VSD), moderate aortic stenosis and carcinoma of the lung, who underwent a successful pneumonectomy. Preoperative and intraoperative assessment of pulmonary artery pressure are essential to manage this combination of cardiac and thoracic pathologies. After pneumonectomy, echocardiography can be difficult. Magnetic resonance imaging (MRI) is useful to assess intra-cardiac defects in this situation.

Key Words: Ventricular septal defect; Lung cancer; Pneumonectomy

	1. Introduction

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
Pneumonectomy remains a relatively high-risk surgical procedure. The presence of a ventricular septal defect (VSD) is a very rare concomitant condition. To date, as far as we are aware, there is only one other case report of a patient undergoing a pneumonectomy who has an uncorrected congenital VSD, a young man with benign disease, unilateral bronchiectasis [1].

	2. Case report

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
A 69-year-old gentleman who had a congenital uncorrected VSD and moderate aortic stenosis, presented with haemoptysis, that required a left pneumonectomy for squamous cell carcinoma.

Preoperative echocardiography confirmed he had moderate aortic stenosis with a mean gradient of 30 mmHg, good left ventricular function, and a subaortic VSD. The shunt was 2:1, and the pulmonary artery systolic pressure was 46 mmHg.

Preoperative FVC was 2.62 l (71.5%), FEV₁ was 1.68 l (59.9%) and DLCO/VA was 1.62 mmol/min/kPa/l (128.4%). Postoperative predicted FEV₁ (1 l, 37%) and DLCO/VA (0.97 mmol/min/kPa/l, 38%, half predicted secondary to VSD shunt of 2:1), based on the 19 bronchopulmonary segment model and a quantitative VQ scan (left lung perfusion 39%, ventilation 34%) revealed he had sufficient pulmonary reserve for a left pneumonectomy.

He underwent a left thoracotomy. Prior to dividing any vascular structures the pulmonary artery was clamped for a period of ten minutes. The proximal pulmonary artery pressure, the central venous pressure, mean arterial pressure and arterial saturations were monitored. No change was observed indicating that in the short-term he would be fine. We proceeded to perform an extra-pericardial pneumonectomy without complication. He was discharged home without complication.

	3. Discussion

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
Patients with carcinoma of the lung who have a VSD and need a pneumonectomy have not been reported previously in the literature.

Patients undergoing pneumonectomy face an operative mortality of 5–7%. Numerous factors elevate this risk including poor lung function, pulmonary hypertension, and co-morbid medical conditions.

VSDs cause pulmonary hypertension, due to the increased right to left blood flow. When the pulmonary hypertension reaches systemic levels the shunt reverses (i.e. initially left to right and then right to left) and the patient develops Eisenmengers syndrome. Pneumonectomy involves a doubling of the pulmonary vascular resistance, which in the presence of fixed pulmonary hypertension can be fatal, due to right heart failure.

Our patient had a subaortic/perimembranous congenital VSD, which was restrictive, as demonstrated by the fact that his pulmonary artery systolic pressure was only mildly raised at 46 mmHg.

Patients with atrial septal defects undergoing pneumonectomy are well described in the surgical literature. Pneumonectomy can result in an increased atrial shunt or the opening of a previously closed but patent foramen ovale [2]. In VSD the shunt can actually decrease, but this results in an increased workload for the right ventricle, potentially causing right heart failure.

Unfortunately catheter closure of VSDs is only appropriate in muscular and selected perimembranous cases, precluding this patient.

Postoperative echocardiography was unfortunately unable to evaluate the pulmonary artery pressure or VSD shunt, due to the mediastinal shift that had occurred post-pneumonectomy. No ASD was detected. After nine months he started getting increasingly short of breath, with an unchanged chest X-ray. A cardiac MRI was performed (Fig. 1, video 1) which demonstrated significant aortic stenosis, mean gradient 55 mmHg, and the sub-aortic VSD.

View larger version (153K): [in this window] [in a new window]   Fig. 1. MRI demonstrating aortic stenosis, a sub-aortic VSD, and a left pneumonectomy. AS, aortic stenosis; PA, pulmonary artery; VSD, ventricular septal defect.

View larger version (149K): [in this window] [in a new window]   Video 1. MRI demonstrating aortic stenosis, a sub-aortic VSD, and a left pneumonectomy.

	References

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 

1. MacGillivray RG, Rocke DA, Shama DM, Mitha AS. Pneumonectomy in a patient with ventricular septal defect. Anaesthesia 1988;43:226–228.[Medline]
2. Zueger O, Soler M, Stulz P, Jacob A, Perruchoud AP. Dyspnea after pneumonectomy: the result of an atrial septal defect. Ann Thorac Surg 1997;63:1451–1452.[Abstract/Free Full Text]

This Article Abstract Full Text (PDF) On-line video Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Michael Poullis Richard Warwick Michael Shackcloth Permission Requests Google Scholar Articles by Poullis, M. Articles by Ridgeway, T. PubMed PubMed Citation Articles by Poullis, M. Articles by Ridgeway, T.