Impact of Approach and Hospital Volume on Cardiovascular Complications After Pulmonary Lobectomy

Abstract

Background: Cardiovascular complications contribute significantly to the morbidity and resource utilization after pulmonary resections. Maturation of less-invasive technologies, such as video and robot-assisted thoracoscopic surgery, aims at improving postoperative outcomes by reducing the trauma of surgery. The present work aimed to evaluate changes in cardiovascular complications after open and minimally invasive lobectomies in the United States.

Methods: We performed a retrospective analysis of the Nationwide Inpatient Sample for patients having elective open, video-assisted, and robot-assisted thoracoscopic lobectomy during 2008-2014. Logistic regression was performed to determine predictors of in-hospital mortality, myocardial infarction (MI), cardiac arrest (CA), and postoperative pulmonary embolism (PE).

Results: A total of 201,226 patients underwent pulmonary lobectomy over the study period. Open thoracotomy (OPEN) approach has steadily decreased from 75%-52% (P < 0.0001), whereas minimally invasive surgery (MIS) utilization has increased from 25%-48% (P < 0.0001) of all lobectomies. MIS approach was independently associated with decreased odds of mortality (odds ratio [OR] 0.6, 95% confidence interval [CI] 0.50-0.73) and PE (OR 0.67, 95% CI 0.50-0.91). MIS patients at high volume institutions had the lowest odds of all-cause mortality (OR 0.27, 95% CI 0.26-0.53) and MI (OR 0.57, 95% CI 0.38-0.87). Operative approach and institutional lobectomy caseload reduced odds of mortality after MI, CA, or PE. Overall, the incidence of MI, CA, and PE increased.

Conclusions: MIS lobectomies increased without a concurrent reduction in perioperative MI, CA, or PE incidence. High hospital lobectomy volume and MIS approach decrease odds of failure to rescue. Improved perioperative management of cardiovascular risk is warranted to reduce the morbidity, mortality, and resource utilization associated with these complications.

Keywords: Cardiovascular complications; Failure to rescue; Pulmonary lobectomy; Thoracoscopy; Thoracotomy; Volume-outcome.