From the Guidelines
Preoperative cardiac clearance for high-risk patients undergoing Robotic Video-Assisted Thoracic Surgery (R VATS) with wedge resection and talc pleurodesis should include a comprehensive cardiovascular evaluation, as outlined in the ACC/AHA 2007 guidelines 1. This evaluation should start with a detailed history and physical examination, followed by a 12-lead ECG and basic laboratory tests including complete blood count, comprehensive metabolic panel, and coagulation studies. High-risk patients should undergo a formal cardiology consultation and additional testing based on their specific risk factors, such as:
- Echocardiography to assess left ventricular function
- Stress testing (exercise or pharmacological) to evaluate for inducible ischemia
- Possibly coronary angiography for patients with significant findings Optimization of cardiac medications is essential, including:
- Continuing beta-blockers (such as metoprolol 25-100 mg twice daily) throughout the perioperative period if the patient is already taking them
- Holding ACE inhibitors or ARBs on the morning of surgery to avoid intraoperative hypotension
- Careful consideration of antiplatelet therapy management - aspirin may be continued for patients with coronary stents, while P2Y12 inhibitors like clopidogrel should be discontinued 5-7 days before surgery if possible
- Continuing statins throughout the perioperative period The anesthesia team should be informed of all cardiac risk factors to prepare for appropriate intraoperative monitoring, which may include arterial line placement and possibly transesophageal echocardiography. These comprehensive measures are necessary because thoracic procedures like R VATS can cause significant hemodynamic and physiologic stress, particularly in patients with underlying cardiac disease, and proper cardiac clearance helps minimize perioperative cardiac complications, as supported by the guidelines 1. It is also important to assess the patient's functional capacity, which can be expressed in metabolic equivalent (MET) levels, as a patient who cannot meet a 4-MET demand with most normal daily activities has increased perioperative cardiac and long-term risks, as noted in the updated guidelines for perioperative cardiovascular evaluation for noncardiac surgery 1.
From the Research
Preoperative Cardiac Clearance Requirements
The preoperative cardiac clearance requirements for a patient undergoing Robotic Video-Assisted Thoracic Surgery (R VATS) with wedge resection and talc pleurodesis who is at high risk for cardiac complications include:
- Assessment of the patient's cardiovascular disease using historical and clinical evaluations and risk indices 2
- Nonroutine preoperative cardiovascular testing, including exercise and Holter electrocardiography, radionuclide ventriculography, stress echocardiography, and dipyridamole thallium scintigraphy 2
- Evaluation of the patient's functional status and the presence of coronary disease to determine the need for further testing or intervention 2
Cardiac Risk Factors
Patients undergoing R VATS with wedge resection and talc pleurodesis may have cardiac risk factors, including:
- Obesity, with a higher body mass index (BMI) 3
- Complex cardiac operation history 3
- Anticoagulation and antiplatelet therapy 3
- Age and sex, with older patients and males being at higher risk 4, 3
Anesthesia and Monitoring
The use of conscious analgosedation with monitored anesthesia care (MAC) may be effective and safe for patients undergoing VATS talc pleurodesis, with minimal risks of complications 5
- Local anesthesia with 0.2% ropivacaine and midazolam and sufentanil or remifentanil infusion can provide adequate analgosedation 5
- Standard monitoring, including ECG, heart rate, non-invasive blood pressure, transcutaneous carbon dioxide, and oxygen saturation, is necessary to ensure patient safety 5
Surgical Outcomes
The surgical outcomes for patients undergoing R VATS with wedge resection and talc pleurodesis include: