Acute right ventricular failure after lobectomy despite an acceptable preoperative cardiopulmonary exercise testing

SESSION TITLE: Critical Care Case Report Posters 48 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Pulmonary resection is increasingly being considered in patients with early-stage lung cancer as a curative therapy. Postoperative pulmonary complications are common, and some of them carry high morbidity and mortality [1]. Acute Right Ventricular Failure (ARVF) is one of the rare postoperative complications after lobectomy. This is a case report of acute right ventricular failure developing on post-op day 2 after a successful right upper lobectomy. CASE PRESENTATION: We present a case of a 76-year-old man who underwent right upper lobectomy for stage IIB adenocarcinoma diagnosed by navigational bronchoscopy. Due to difficulty dissecting the fissure, video-assisted thoracoscopic surgery was converted to open thoracotomy. Otherwise, the intraoperative period was uneventful, with successful extubation after the surgery. On postoperative day two, he became progressively hypoxic, and hypotensive, requiring multiple vasopressors and 100% FiO2 including paralysis. As a bedside echocardiogram revealed McConnell's sign, Right Heart Catheterization (RHC) was done that confirmed acutely elevated pulmonary pressures with increased Peripheral Vascular Resistance (PVR).Further diagnostic workups were negative for acute pulmonary embolism, right ventricular infarct, and torsion of the remaining right lobes. There was evidence of pneumonia with consolidation in the right lower lobe on imaging of the chest, and elevated procalcitonin. A bedside bronchoscopy revealed good integrity of the stump, mild torsion of the right middle lobe as an expected finding, and Mucous plugs which were suctioned with BAL specimens positive for E.coli and Serratia. He was started on broad-spectrum antibiotics. ARVT was managed with pre-load reduction with ultrafiltration by CRRT and afterload reduction with pulmonary vasodilators that included Veletri and Sildenafil. He was successfully extubated on the seventh day of mechanical ventilation with the reversal of organ failure indices, including transaminases and creatinine. He was discharged to acute rehab on the tenth day. Upon follow-up in six weeks, he demonstrated normalization of pulmonary pressures with RHC. In his recent visit, he can carry out activities of daily living with significant improvement in the 6-minute walk test and remains off pulmonary vasodilators. DISCUSSION: Acute right ventricular failure can have high morbidity and mortality, if not recognized early. Our case report is an example of the complex heart-lung interactions leading to acute right ventricular failure, despite acceptable pre-operative cardiopulmonary exercise testing. In our case, it is likely secondary to a sudden increase in pulmonary afterload due to a combination of lobectomy, hypoxic pulmonary vasoconstriction due to mucous plug and pneumonia. Lobectomy reduces the available vascular bed for RV output, thus lowering pulmonary vascular resistance according to Laplace law. [2] [3]. The best approach to ARVF after lobectomy is prompt identification by a bedside echo, ruling out acute pulmonary embolism, torsion of lobes and right ventricular infarct, aggressive cardiopulmonary resuscitation, pre-load reduction despite being on multiple vasopressors and prompt institution of pulmonary vasodilator therapy. [4]. In our case, the patient required systemic pulmonary vasodilator therapy for a total of 3 weeks CONCLUSIONS: Our case was an example of how understanding the pathophysiology of complex heart-lung interactions led to a better outcome in managing Acute right ventricular failure. REFERENCE #1: Rosen JE, Hancock JG, Kim AW, et al. Predictors of mortality after surgical management of lung cancer in the national cancer database. Ann of Thorac Surg. 2014 REFERENCE #2: Konstam M.A., Kiernan M.S., Bernstein D., Bozkurt B., Jacob M., Kapur N.K., Kociol R.D., Lewis E.F., Mehra M.R., Pagani F.D., Raval A.N., Ward C. Evaluation and management of right-sided heart failure: a scientific statement from the American Heart Association. Circulation. REFERENCE #3: Okada M., Ota T., Okada M., Matsuda H., Okada K., Ishii N. Right ventricular dysfunction after major pulmonary resection. J Thorac Cardiovasc Surg. 1994;108:503–511. DISCLOSURES: No relevant relationships by Joanna Kristeva No relevant relationships by Nway Nway No relevant relationships by Ramakanth Pata No relevant relationships by Myo Myint Tun