MIYAHARA ET AL TOTAL ARCH REPLACEMENT IN PATIENTS WITH COPD
79
INVITED COMMENTARY Miyahara and colleagues [1] have provided an interesting analysis on the influence of chronic obstructive pulmonary disease (COPD) on the outcome of total arch replacement. The association between aortic wall degeneration and destruction of lung tissue is under current debate. COPD as well as aortic disease are important morbidities of an aging population. The prevalence of lung disease in patients with aortic disease is high, reaching up to 47% of patients with aortic arch pathologies and to even higher rates of 55% in patients with abdominal aortic aneurysms [2, 3]. For this reason, careful preoperative assessment, especially spirometry, is usually recommended but carries a potential risk for patients with thoracic aortic disease due to changes of intrathoracic pressure. To avoid potential harm, patients are not assessed by spirometry preoperatively, and the presence or severity of COPD is overlooked or remains underdiagnosed. The data of Miyahara and colleagues [1] once again underline the importance of COPD as a risk factor for in-hospital death as well for postoperative pulmonary complications. Especially patients undergoing aortic arch replacement necessitating deep hypothermic circulatory arrest should be evaluated very carefully for preoperative lung disease. Ischemia-reperfusion can be the initiating factor for pulmonary dysfunction during and after extracorporeal circulation and can possibly induce devastating damage to already diseased lung tissue. Experimental data reveal an increase of inflammation factors interleukin-8 and interleukin-6, as well as activation of nuclear factor-kB,
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
and might explain the mechanism of deep hypothermic circulatory arrest–induced pulmonary injury [4]. In summary, their report reflects daily clinical routine: the vast majority of patients with mild to moderate COPD do well, even after extended aneurysm repair. Those patients presenting with severe COPD and the definitive need deep hypothermic circulatory arrest have to be assessed very carefully. Julia Dumfarth, MD Michael Grimm, MD Department of Cardiac Surgery Medical University of Innsbruck Anichstrasse 35 A-6020 Innsbruck, Austria e-mail: [email protected]
References 1. Miyahara S, Nakai H, Izawa N, et al. Influences of chronic obstructive pulmonary disease on outcomes of total arch replacement. Ann Thorac Surg 2015;99:72–9. 2. LeMaire SA, Price MD, Parenti JL, et al. Early outcome after aortic arch replacement by using the Y-graft technique. Ann Thorac Surg 2011;91:700–7. 3. Fowkes FG, Anandan CL, Lee AJ, et al. Reduced lung function in patients with abdominal aortic aneurysm is associated with activation of inflammation and hemostasis, not smoking or cardiovascular disease. J Vasc Surg 2006;43:474–80. 4. Zheng JH, Gao BT, Jiang ZM, Yu XQ, Xu ZW. Evaluation of early macrophage activation and NF-kappaB activity in pulmonary injury caused by deep hypothermia circulatory arrest: an experimental study. Pediatr Cardiol 2010;31:215–21.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.09.002
ADULT CARDIAC
Ann Thorac Surg 2015;99:72–9
79
INVITED COMMENTARY Miyahara and colleagues [1] have provided an interesting analysis on the influence of chronic obstructive pulmonary disease (COPD) on the outcome of total arch replacement. The association between aortic wall degeneration and destruction of lung tissue is under current debate. COPD as well as aortic disease are important morbidities of an aging population. The prevalence of lung disease in patients with aortic disease is high, reaching up to 47% of patients with aortic arch pathologies and to even higher rates of 55% in patients with abdominal aortic aneurysms [2, 3]. For this reason, careful preoperative assessment, especially spirometry, is usually recommended but carries a potential risk for patients with thoracic aortic disease due to changes of intrathoracic pressure. To avoid potential harm, patients are not assessed by spirometry preoperatively, and the presence or severity of COPD is overlooked or remains underdiagnosed. The data of Miyahara and colleagues [1] once again underline the importance of COPD as a risk factor for in-hospital death as well for postoperative pulmonary complications. Especially patients undergoing aortic arch replacement necessitating deep hypothermic circulatory arrest should be evaluated very carefully for preoperative lung disease. Ischemia-reperfusion can be the initiating factor for pulmonary dysfunction during and after extracorporeal circulation and can possibly induce devastating damage to already diseased lung tissue. Experimental data reveal an increase of inflammation factors interleukin-8 and interleukin-6, as well as activation of nuclear factor-kB,
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
and might explain the mechanism of deep hypothermic circulatory arrest–induced pulmonary injury [4]. In summary, their report reflects daily clinical routine: the vast majority of patients with mild to moderate COPD do well, even after extended aneurysm repair. Those patients presenting with severe COPD and the definitive need deep hypothermic circulatory arrest have to be assessed very carefully. Julia Dumfarth, MD Michael Grimm, MD Department of Cardiac Surgery Medical University of Innsbruck Anichstrasse 35 A-6020 Innsbruck, Austria e-mail: [email protected]
References 1. Miyahara S, Nakai H, Izawa N, et al. Influences of chronic obstructive pulmonary disease on outcomes of total arch replacement. Ann Thorac Surg 2015;99:72–9. 2. LeMaire SA, Price MD, Parenti JL, et al. Early outcome after aortic arch replacement by using the Y-graft technique. Ann Thorac Surg 2011;91:700–7. 3. Fowkes FG, Anandan CL, Lee AJ, et al. Reduced lung function in patients with abdominal aortic aneurysm is associated with activation of inflammation and hemostasis, not smoking or cardiovascular disease. J Vasc Surg 2006;43:474–80. 4. Zheng JH, Gao BT, Jiang ZM, Yu XQ, Xu ZW. Evaluation of early macrophage activation and NF-kappaB activity in pulmonary injury caused by deep hypothermia circulatory arrest: an experimental study. Pediatr Cardiol 2010;31:215–21.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.09.002
ADULT CARDIAC
Ann Thorac Surg 2015;99:72–9
