The Electrocardiogram After Lung Resection in Children

The Electrocardiogram After Lung Resection in Children" HOMOBONO

B.

CALLEJA, M.D.,

F~C.C.P.**

AND RONALDO

G.

ASUNCION, M.D.t

Quezon City, Philippines

AT

n

THE TURN OF THE FOURTH DECADE

of this century when pneumonectomy became a safe procedure, Graham inquired: "With how little lung tissue is life compatiblei''" Subsequently, various studies after pneumonectomies in children'" and adults'? have shown only minimal change from the over-all resting pulmonary function. There was no mention of the longterm effects on the electrocardiogram. The present communication deals specifically with the electrocardiogram of 104 children followed one year to 12 years after lung resection. This study was undertaken to find out the: (1) evolution of cor pulmonale as revealed by the evidence of right ventricular strain and/or hypertrophy in the electrocardiogram, and (2) other electrocardiographic changes that may characterize the long-term follow-up of this group. MATERIAL AND METHOD

One-hundred twelve children from five to 15 years had lung resection at Quezon Institute, Quezon City, Philippines. Of these, 22 had right pneumonectomy and 48 lobectomies and/or segmental resections. A clinical check-up with emphasis on the pulmonary symptoms and signs was done in each ranging from one year to 12 years after operation. To facilitate clinical evaluation and correlation, a classification was worked out. This classification is paraphrased from the New York Heart Association functional classification for heart disease" and is as follows: Class I. Post-resection patients without limitation of physical activity. Ordinary physical activity does not cause undue fa*From The Amerman Heart Clinic Foundation, Quezon City. This work was supported in part by a grant from Mrs. Alice Amerman Deutsch, I nglewood, California. **Director, Amerman Heart Clinic Foundation, Quezon City. t Radiologist, Amerman Heart Clinic Foundation, Quezon City.

456

tigue, palpitation, dyspnea or chest pain. (Chest pain refers to pulmonary hypertension pain which mayor may not be identical to angina pectoris). Class II. Post-resection patients with slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea or chest pain. Class III. Post-resection patients with marked limitation of physical activity. They are comfortable at rest. Less physical activity causes fatigue, palpitation, dyspnea or chest pain. Class IV. Post-resection patients unable to carryon any physical activity without discomfort. Symptoms of pulmonary insufficiency are present even at rest. If any physical activity is undertaken, discomfort is increased. The position of the heart was noted in the teleradiogram taken within one week of the electrocardiographic tracing and recorded as follows: 1. Normal position - the left cardiac border is within the left midclavicular line and the right border is at the right sternal border or only slightly to the right. 2. Left - cardiac silhouette is entirely in the left hemithorax. There is no cardiac shadow at the right sternal border. 3. Center - cardiac silhouette is behind the sternum seen about as much to the left as to the right of the vertebral shadow. 4. Right - cardiac silhouette is mostly or entirely in the right hemithorax. All patients had 12-lead electrocardiograms in their current check-up and all but nine had preoperative tracings. Many had two to three tracings ofter operation. Additional chest leads V 3R-OR' V 7-8 were also recorded in the most recent postoperative electrocardiogram.

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T ABLE I-RIGHT PXEI!MO :';EGTOMIES Age O perated

Presenl Age"

5 years 6

14 years I.j. 12·1 3 13 13·1 5 16 13·1 6 15· 23 15· 24 25

7

8

9

10 II 12 13 IS T otal

457

'I ~ ;') (, ~ THE E L E CTROCARDIO GRAM AFT ER L UN G RESECTION IN C HILDRE N

xe.

Cas t's

2 I 3 I 3 4 4 )

21

Sex F M M -2 M F· 2 : M-I M M· 3 F·I : M· 3 F·.j. M F.8 : M-1 3

"-Range ; F- femal e : M-male.

The arbitra ry period chosen for rrurumum follow-up during the postoperat ive course is one year. It was hoped that th e ST -T cha nges occur ring in the immediate postoperat ive period sha ll have disappear ed by the end of the first year and the heart sta bilized in th e new locus in the chest. Six left pneumonectomies, one right pneum onectom y and one lobectomy with less th an one year follow-up were excluded. The re-

mai ning 104 patients composed the material for this investigation. R ES ULTS

O ne-hund red four pat ients were followed one year to 12 years after opera tion. All received a clinical check-up, teleradi ogram and electroc ardiogram at the ir last visit. R igh t pneu mo ne ctomy group: Twent y-one pat ients out of 22 were followed up after opera tion. T he age at the tim e of operation, age at the last visit and sex distribution are shown in Table 1. All patient s were in class I of the functional classification. There was no eviden ce of cor pulmonale before and after opera tion. The electrocardi ogram before operation was normal in 15 including two with incomplete right bu ndle bran ch block. There were no preoperative electrocardiograms in five. In one the Q-I , II , V:H ; pattern was present before opera tion. T he " P" pulmonale pattern was present in one before and after opera tion and in ano ther it appeared

. ,.

FIGURE I : D. F . boy, age I S. Tracings ar e three months ( upper) and six years (lo wer ) aft er righ t pneumonect omy . Not e accentu ation of Q . I, II , V o_o upright T wave pa ttern an d th e shift ing of the transition zone to th e righ t. Leads Vea.sa show the norm al righ t ven tric ular morphology and V,n the transition com plex.

45 8

Diseases of the Chest

CALLEJA AND ASUNCION

Age Operated

TABLE 2-RIGHT PNEUMOSECTOMIES Q-I, II, V.... No. Cases Preop.

Postop .

5 years

I

N

X

6

I

No ECG

X

7

2

N-2

X-2

B

I

N

N

9

3

N-2 No ECG-I

N-I X-2

N (IRBBB)

X

10 II

3

N-I X-I No ECG-I

N-I X-2

12

4

N-4

N-2 X-2

13

4

N-3 (IRBBB-I) No ECG-I

~-I

No ECG

X

N-15 X-I No ECG-5

N-B X-13

15 Total

21

N-3 (IRBBB-I)

N--Nonnal with no Q-I, II, V.... pattern ; X-tracing with Q-I, II , V.... pattern ; IRBBB-incomplete right bundle branch block.

postoperatively. In both, corollary signs suggestive of right ventricular strain or hypertrophy were wanting. The postoperative electrocardiogram was conspicuous with the appearance of Q-I, II, V 5-6 pattern. This pattern was present in 13 (Table 2) . Eight patients showed little or no change in the postoperative electrocardiogram. The Q-I, II, V 5-6 pattern

was accompanied by a shift in the transition zone to the right in the precordial leads (Fig. 1) . The position of the heart in the chest was in the right hemithorax in all except five. In two the heart was approximately in normal position (Fig. 2) ; another two central and in one moderately displaced to the right.

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~ ~ ~ ~ :W ~ ~ iF1

FIGURE 2 : Z. R. woman , age 24, 11 years after right pneumonectomy. The heart remains in normal position and the electrocardiogram has normal R/S progression in the precordial leads.

Volume ~O . No. ~ November. 1966

459

THE ELECTROCARDIOGRAM AFTER LUNG RESECTION IN CHILDREN

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I

-~--r---("'-

1

I

I

2

_ .1\1

-

FIGURE 3: C. C. 17·year·old girl , three years after pneumonectomy. Upper two tracings are 14 months and 12 months respectively before operation ; lower tracings are three months and three years respectively after pneumonectomy. From top to bottom, note increasing RAD, increasing S wave in Ve, increasing clockwise rotation and evolution of RSR' in V, . Teleradiogram shows heart in the left chest .

Left pneumonectomy group:

There were 36 patients who had one year to 12 years follow-up after operation.· Table 3 shows their age and sex distribution. One died of chronic cor pulmonale due to progressive pulmonary tuberculosis five years after pneumonectomy. Another had right ventricular hypertrophy (RVH) before operation and the postoperative electrocardiograms at three months and nine years showed evidence of increasing right heart strain with tall R wave in V 1- 2 and inverted T wave in V I - 6 (Table 1), although clinically he was still in Class 1. Except for one patient who died, all were TABLE 3-LEFT PNEUMONECTOMIES Age Operated

Present Age*

No. Cases

5 years 6 7 8 9 10 11 12 13 14 IS Total

II years 11-12 12-19 II-IS 10 15-16 12·23 13·18 18-22 17-26 20-27

2 2 3 4 2 2 6 3 3 3 6 36

*-Range ; F-female ; M-male.

Sex

F-2 : F-I : F-I : F-4 : F-I: F-2 : F-18 :

F-2 M-2 M-I M-3 M·I F-2 M·2 M-2 M·3 F-3 M-4 M-18

in class I with no restriction of physical activity. The preoperative electrocardiograms were normal in 31 with incomplete right bundle branch block pattern (IRBBB) in seven and right axis deviation (RAD) in 15 (Table 1) . One had RVH. Four had no electrocardiogram before operation. After operation, 31 were normal, 18 of whom had IRBBB. Seven who had IRBBB before operation showed persistence of the same pattern after pneumonectomy, but became associated with RAD and clockwise rotation. Right axis deviation was present in 13 of 18 with IRBBB and in only two without IRBBB.Figure 3 shows a typical evolution of RAD, RSR' wave in V 1 and clockwise rotation after left pneumonectomy. It was also noted that additional leads V.. and V ~ show disappearance of S wave (Fig. 1). First degree A-V block appeared in the postoperative electrocardiogram of one patient. The pattern of "P" pulmonale was not seen in this group. The position of the heart was less discernible after left pneumonectomy than in the case of right pneumonectomy because of difficulty in appreciating the cardiac silhouette in the density of the left hemithorax . The heart was thought to be pulled to the left or fixed in about the normal posi-

C t 60

D iseases of the Chest

CALLEJA AND ASUNCION

TABLE 4-LEFT P:-iEUMO:-i ECTOMI ES IRBBB No. Cases Preop .

Age Operated

Postop .

5 years

2

N-I x ( R AD)

6

2

x-2 (RAD - I )

x-2 (RAD)

3

(RAD-I) x-I (RAD-I)

x-3 (RAD)

No ( ECG- I) x-2 (RAD) RVH-I (RAD )

N- I x-2 ( RAD ) RVH*-I ( RAD )

7

~ -2

N-I x-(RAD)

8

4

9

2

N- I x- I (RAD)

N-I x- I (RAD )

10

6

N-I No EC G-I

N-I x-I (RAD )

II

6

N-6 ( RAD-3 )

N-3 (RAD-I) x-3 (RAD - I )

12

3

N-3 (RAD-2)

N-I x-2 ( RAD)

13

3

N-3

N-2 (RAD-2)** RVH-I (R AD)

14

3

N-3 (RAD-2)

N-2 x-I

15

6

N-4 (RAD-2) No ECG -2

N-4 (RAD-I) x-2

T otal

36

N-24 ( RAD-8 ) x-7 (RAD -6) RVH-I (RAD ) No EC G·4

N-16 (RAD-2 ) x-18 (RAD-13) RVH-2 ( RAD)

IRBBB-Incompl ete right bund le branc h block pa ttern : N- norma l with no IRBBB ; RVHright ventricular hypertroph y ; X-with IRBBB: RVH*-R-V, tall er and T-V, _" inverted compa red to preoperative tra cing ; RAD**-right axis deviat ion and first degre e A-V Block in I case : RAD- right axis deviation.

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1

"

FIGUR E 4 : C . B., 27-year-old man, II years aft er pn eumonectomy. Clockwise rotation , RAD and IRBBB are pr esent. Leads V,.• show progressive disap peara nce of the S wave.

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~ THE ELECTROCARDIOGRAM AFTER LUNG RESECTION IN CHILDREN

I

1

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.

I

..........

I

-

.

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----

461

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FIGURE 5: C.M . 17 year , girl , six years after left lower lobectomy. The electrocardiograms were taken one month before operation (upper), four months post-lobectomy (middle), and six years post-lobectomy (lower) . The electrical axis in the frontal plane remains the same but the S wave in V. _6 becomes deeper indicating some clockwise rotation. The cardiac silhouette is at about normal location in the left hernithorax .

tion in all. None showed traction of the heart to the right hemithorax or even to a central position. The apex may point towards the lateral left chest wall. This can be appreciated by palpation and the electrocardiogram at this location shows left ventricular morphology. The second sound over the pulmonary area was heard best at the left infraclavicular fossa, while the second sound over the aortic area was heard at the upper left sternal border. Lobectomy and/or segmental resection group: Forty-seven patients out of 48 were followed (Table 5). In 21, more than one LOBECTO~IIES

Age Operated 5 years 6 7 8 9 10 II 12 13 14

TABLE 5AXD!OR SEGMEXTAL RESECTIOXS Present No. Age" Cases Sex 10 years 10·17 9-18 10 16-21 15-20 17-23 15-20 16-23 .... 18-27

I

5 5 I 5 3 9

7 3

15 8 47 Total "-Range ; .... -died age 23 years .

F M-3 : F-2 M-:! : F-3 M M-2 : F-3 M-I: F·2 M ·6 : F·3 M-2 : F·5 M-3 M-5 : F-3 M-25 : F-22

lobe was removed, while in 26 one lobe, segment or segments were operated on. The heart was in normal position in 29 patients. central in five, left in 12 and right in one. The postoperative electrocardiogram remained normal with no positional changes except in one with Q-I, II, V:;-G pattern and in another with right axis deviation as a lone finding . One other patient with left lower lobectomy showed progressive increase of S wave in V:;_11 without change in the frontal electrical axis (Fig. 5). One died nine years after a combined right middle and right lower lobectomy with "P" pulmonale and RVH evident in the electrocardiogram two years after operation. He had extensive bilateral bronchiectasis. Two patients were in class II, one with bronchiectasis in the remaining lung and the other with persistent asthma. The "P" pulmonale pattern was observed in two preoperative tracings and in four postoperative electrocardiograms. Notched P wave was present in one before and after operation . DISCUSSION

The pertinent question that comes up in the long-term follow-up of patients with lung resection is the occurrence of chronic cor pulmonale. The electrocardiogram is

Diseases of

CALLEJA AND ASUNCION

universally accepted as a useful tool in the diagnosis of chronic cor pulmonale. The importance of this study therefore lies in the fact that an objective follow-up of the hemodynamic changes brought about in the pulmonary circulation consequent to lung resection is available. Compared to preoperative tracings, the electrocardiogram after operation showed no evolution of RVS or RVH except in two cases. Altogether in the three groups, only three cases of RVH were diagnosed in the postresection electrocardiograms. In particular, these three patients had RVH before and after operation in one and in the other two the development of RVH in the postoperative electrocardiogram was associated with progression of the pulmonary disease. Two of these patients belonged to the left pneumonectomy group and the other to the lobectomy series. It appears that the amount of lung tissue removed is immaterial to the evolution of chronic cor pulmonale in children. This conclusion agrees with the pulmonary function studies of Antonio and associates' which show that there are no significant differences in vital capacities, maximum breathing capacities and air velocity indices between the pneumonectomies and the lobectomies. The "P" pulmonale pattern was observed in only six postresection tracings, two of which were present also in the preoperative electrocardiograms. Further, only one was associated with definite evidence of RVH in the electrocardiogram. Another patient had notched P wave before and after operation. First degree A-V block was present in one post-resection electrocardiogram. As expected, the ST-T changes that occur in the immediate postoperative period have disappeared after one year. On the other hand, positional electrocardiographic changes have occurred in most tracings in those with left or right pneumonectomy and in only three of the lobectomy group. These electrocardiographic changes were all associated with marked shift of the heart to the left or right hemithorax. Characteristic po sit ion a I electrocardiographic

the Chest

changes in pneumonectomies have been described in a previous report. to The pattern of IRBBB, RAD and clockwise rotation appeared in left pneumonectomy while Q-I, II, V 5-6 with upright T pattern appeared in right pneumonectomy. Patients with lobectomies accompanied by marked shift of the heart to either hemithorax also displayed these electrocardiographic patterns. Awareness of these positional electrocardiographic changes is important in avoiding pitfalls in the diagnosis of ventricular hypertrophies after lung resection." SUMMARY

One-hundred four patients comprising of 21 right pneumonectomies, 36 left pneumonectomies and 47 lobectomies and/ or segmental resections were followed up one year to 12 years after operation. The postresection electrocardiograms were analyzed for RVH or RVS and compared with the preoperative tracings. From electrocardiographic evidence alone, the evolution of pulmonary heart disease after lung resection is rare. Regardless of the type or extent of resection, chronic cor pulmonale developed only in those whose pulmonary disease progressed even after operation. Positional electrocardiographic changes characterized the post-resection tracings when the heart was markedly shifted to the right or left hemithorax. After right pneumonectomy, the heart was displaced to the right and the electrocardiogram showed Q-I, II, V 5-6 with upright T wave pattern and a shift of the transition complex to the right. The electrocardiogram after left pneumonectomy showed RAD RSR' in VI and clockwise rotation. Lobectomies and lesser lung resection generally showed little or no shift in the cardiac position, hence no changes in the electrocardiogram. RESUMEN

Ciento cuatro pacientes, sometidos a las siguientes operaciones quinirgicas fueron observados de uno a doce afios, a contar de la fecha de su operaci6n: 21 neumectomias derechas, 36 neumectomias izquierdas, 47 lobectornias 0 resecciones segmentarias. Los ECG postoperatorios fueron analizados en busca de cambios indicativos

Volume 50, No.5 November, 1966 THE ELECTROCARDIOGRAM AFTER LUNG RESECTION IN CHILDREN

de hipertrofia 0 sobrecarga ventricular derecha y comparados con los trazados preoperatorios, A base exclusivamente de los ECG la progresi6n de las neumo-cardiopadas despues de las resecciones aparece raramente. Cualquiera que fuera el tipo 0 extensi6n de la resecci6n el cor pulmonale se present6 solo en los casos en que la neumopatia sigui6 un curso progresivo despues de la operaci6n. Solo cuando el coraz6n experimento un desplazamiento marcado hacia el hemitorax derecho 0 izquierdo se observaron cambios posicionales caracteristicos en el ECG. Despues de la neumectomia derecha el coraz6n se desplazo hacia la derecha y el ECG mostr6 una onda T hacia arriba y transposici6n del complejo transicional hacia la derecha en las derivaciones I, II, V 5-6. Despues de la exeresis del pulm6n izquierdo el ECG revelo DAD, RSR en V derivaci6n y rotacion hacia la izquierda. Las lobectomias y resecciones menores generalmente no fueron seguidasde cambios apreciables en la posici6n del eoraz6n y por 10 tanto no dieron lugar a cambios electrocardiograficos,

war das Herz nach rechts verlagert und das Elektrokardiogramm zeigte a-I, II, V 5-6 mit hochgezogener T-Zacke und einer Neigung der Rechtstransposition des Komplexes. Das Elektrokardiogramm nach linksseitiger Pneumonektomie Zeigte RAD, RSR' in V und eine Rotation im Uhrzeigersinn. Lobektomien und kleinere Lungenresektion zeigten im allgemeinen wenig oder gar keine Abweichungen der Herzlage, ebensowenig Veranderungen im Elektrokardiogramm.

2

3

4

ZUSA~(l\{ENFASSUNG

104 Patienten bei denen naehfolgende Operationen vorgenommen waren, wurden 1-12 Jahre naeh der Operation naehuntersucht: 21 rechtsseitige Pneumonektomien, 36 linksseitige Pneumonektornien, 47 Lobektomien und Zoder Segmentresektionen. Die Elektrokardiogramme naeh der Resektion wurden analysiert hinsiehtlich RVH oder RVS und verglichen mit den Elektrokardiogrammen vor der Operation. Naeh den elektrokardiographischen Annaltspunkten a II e i n zu urteilen, ist die Entwichlung einer pulmonalen Herzerkrankung nach der Lungenresektion selten. Unbeschadet der Art oder des Ausmajses der Resektion entwickelte sich ein chronisches cor-pulmonale nur bei solchen Patienten, deren Lungenerkrankung nuch nach der Operation noch fortschritt. Elektrokardiographische lagebedingte Veranderungen charakterisierten die Elektrocardiogramme nach der Resektion, sofem das Herz deutlich in den reehten oder linken Halbthorax verschoben war. Nach rechtsseitiger Pneumonektomie

5 6

7

8

9

10

REFERENCES GRAHAM, E. A.: "With How Little Lung Tissue is Life Compatible?," Surgery, 8: 239, 1940. LESTER, C. W., COURNAND, A. AND RILEY, R. L.: "Pulmonary Function After Pneumonectomy in Children," [, Thoracic Surg., 11: 529, 1942. COURNAND, A., HIMMELSTEIN, A., RILEY, R. L. AND LESTER, C. W.: "A Follow-up Study of the Cardio-Pulmonary Function in Four Young Individuals After Pneumonectomy," [, Thoracic Surg., 16:30, 1947. PETERS, R. M., Roos, A., BLOCX, H., BURFORD, T. H. AND GRAHAM, E. A.: "Respiratory and Circulatory Studies After Pneumonectomy in Childhood," [, Thoracic Surg., 20:484, 20:484, 1950. FRIEND, J.: "Respiratory Insufficiency After Pneumonectomy," Lancet, 2: 260, 1954. McILROY, M. B. AND BATES, D. W.: "Respiratory Function After Pneumonectomy," Thorax, 11: 303, 1956. BURROWS, B., ILuuuSON, R. W., ADAMS, W. E., HUMPHREYS, E. M., LoNO, E. T. AND REIMANN, A.: "The Post-pneumonectomy State: Clinical and Physiologic Observations in Thirtysix Cases," Am. t. Med., 28:281, 1960. New York Heart Association, Inc.: Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Blood Vessels, (5th Ed.), Peter F. Mallon, Inc., Now York, 1953. ANTONIO, R., PARDO DE TAVERA, M., CALLEJA, H. B., DE LEON, E. P.: "Lung Resection in Filipino Children. III. Pulmonary Function 1 Year to 12 Years After Operation," Presented at the 8th International Congress on Diseases of the Chest, Mexico City, Oct. 15, 1964. CALLEJA, H. B.: "Diagnostic Value of Electrocardiographic Chan ge sin Pneumonectomies," Cardiologia, (In press).

For reprints, please write: Dr. Calleja, 316 Quezon Blvd. Extension, Quezon City, Philippines.

MANAGEMENT OF SPONTANEOUS PNEUMOTHORAX a 92 per cent follow-up, was 12.5 per cent. There This paper describes 242 consecutive cases of spontaneous pneumothorax treated In a thoracic surgical was no recurrence after thoracotomy. The recurunit. One hundred eighty-four patients were treated rence rate after intubation was 14.3 per cent. by pleural catheterization and 49 by thoracotomy: 11 RUCK LEY, C. V. AND MCCORMACK. R. r, M.: "The Manwith very small pneumothoraces were treated conagement of Spontaneous Pneumothorax," T'bore», 21:139, servatively. The overall recurrence rate, shown by 1966.