2022 European Society of Cardiology guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery: which impact to lung cancer resection?

In August 2022, the European Society of Cardiology, with endorsement of the European Society of Anesthesiology and Intensive Care, issued the updated guidelines regarding overall management of patients scheduled for non-cardiac surgery (1). The document contains a massive amount of new concepts, updates and revisions, and first of all the surgical community should express gratitude to all the colleagues who contributed to this challenging task. The ESC guidelines embrace several points, each one representing a daily challenge in decision-making processes, especially when dealing with patients with cardiovascular risk factors. The topics touched deal with preoperative assessment of cardiac function, management of blood thinners, risk reduction strategies, and many others points. While issued recommendations are not meant to be oriented to a specific surgical field, their connection to the main key points of lung cancer surgery is very strict. Indeed, compared to other surgical subspecialties, lung resections carry myriads of cardiac and vascular implications. First of all, lung cancer patients are very often current or former smokers, which implies a higher risk of coronary artery disease and other cardiovascular comorbidities. Furthermore, thoracic surgery exposes patients to postoperative cardiovascular complications also due to its specific pathophysiologic changes and anatomical relationships. Possible specific mechanisms of cardiac involvement during and after lung surgery are (but not limited to): increased right ventricular dysfunction secondary to lung tissue removal (2, 3), induction of arrhythmias due to vagus nerve injury (4, 5), induction of postoperative hypoxia due to chest pain and phlegm retention, and reduced blood venous return in case of massive mediastinal shift. Several recommendations from updated ESC guidelines intimately deal with all these points and deserve a focused comment. For example, in the new recommendations section, it is mentioned that minimally-invasive accesses can be adopted as a risk-reduction strategy. In lung cancer surgery, this means that video-assisted procedures (VATS) in lieu of open thoracotomy should be strongly considered as the best option for performing lung resection, especially to patients with high cardiovascular risk. However, the class of recommendation is regarded as IIa, meaning that – even though VATS should be considered as the best choice the indication is still not compulsory. The recommendation seems reasonable, by virtue on the current knowledge on this topic. Certainly, in the last two decades, VATS has become the standard method to perform lung resection in an increasing number of surgical centers all around the world. The rationale of this revolution is that patients are assumed to benefit from the reduced surgical traumatism and reduced postoperative chest pain. Both these factors should lead to a faster recovery and less inflammatory perturbation, ultimately translating into lesser mortality and morbidity. However, it should be highlighted that a very strong evidence in favor of VATS versus open surgery was not available until recently. Indeed, despite of the exponential increase of patients undergoing VATS resections and the large amount of literature reporting excellent results, many studies on this topic were retrospective in nature. Furthermore, the few available randomized-controlled trials (RCTs) either did not have cardiovascular complications rate as the main endpoint (5), or they were not double-blinded with a potential for expectance bias (6). In August 2021, the early results of a large, multicenter RCT VIOLET study become available. This is probably the largest study so far on this topic, as it involved 9 teaching hospitals in the United Kingdom (7). Interestingly, the study was blinded to both patients and non-operating medical and nurse staff. The VIOLET trial showed that, compared to open thoracotomy, VATS lobectomy can achieve a significant reduction of postoperative morbidity. In particular, readmission rate and incidence of serious events after discharge were both significantly lesser after VATS, thus suggesting that the benefits of a minimally-invasive approach can extend themselves beyond the immediate perioperative phase.