Introduction
By American college of chest physician guideline, calculating predicted postoperative lung functions before lung resection surgery in lung cancer patients without cardiac problems is known to be an important predictor of postoperative mortality.
Here, we report a rare case that in cardiopulmonary exercise testing (CPET) as preoperative assessment before lung cancer resection surgery found severe coronary artery obstructive disease (CAOD) and the surgery was postponed.
Case report
A 68 year-old male visited department of pulmonary medicine complaining dyspnea on exertion for 3 months. He had history of hypertension, 9 pack-years of smoking and quit 30 years ago. On chest computed tomography revealed 1.4 cm-sized nodule at the left posterior basal segment, and he was referred to the department of thoracic surgery and planned for surgical approach. For taking preoperative assessment, he was referred to the department of rehabilitation medicine. Pulmonary function test showed mild obstructive pattern, suggesting chronic obstructive pulmonary disease (COPD). In 6 minute walk test, he walked for 490 m, 78% of predicted value. He was admitted the day before surgery and took CPET for the last preoperative assessment. The test was performed under modified Bruce protocol. From stage 3, he complained intermittent chest discomfort and systolic blood pressure was decreased by 10 mmHg, in stage 4. From stage 4, ST depression was noted by 1.5 to 1.8 mm at V4 to V6 lead with horizontal and down sloping. In stage 5, patient complained dyspnea and severe chest discomfort, and the test was suspended after 1 minute and 20 seconds elapsed. In recovery stage, his uncomfortable symptoms gradually disappeared (Table 1).
According to the result of preoperative CPET, we recommended that previous surgical plan should be held immediately and the confirmation for the coronary artery problem was needed by cardiologist. Coronary angiography revealed discrete 95% of stenosis on descending right coronary artery and percutaneous coronary intervention was performed with drug-eluting stent, taking dual antiplatelet therapy (Fig. 1). After 4 weeks, he got left lower lobe lobectomy safely without concern of CAOD.
Conclusion
According to preoperative algorithm of cardiac evaluation by European respiratory society, he had no risk of cardiac problem and there was no need for further evaluation such as CPET due to small resection area. Because it is difficult to distinguish coronary artery problem by routine preoperative examinations, we need to consider the importance of CPET as preoperative assessment before lung cancer resection surgery such as this rare case. In addition, it should be remembered that CPET is a useful test to distinguish dyspnea on exertion from angina in patients with COPD or healthy persons.
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