[Comprehensive Preoperative Evaluation of Patients with Lung Cancer]. / Umfassende präoperative Evaluation von Patienten mit Lungenkrebs.

Surgical resection continues to be a mainstay of curative treatment of patients with non-small cell lung cancers stages I - III and some small cell lung cancers. Reported rates of complications and mortality vary considerably. Therefore, a thorough and comprehensive preoperative evaluation of lung cancer patients is crucial in order to select appropriate surgical candidates and to determine their individual risk, including the extent of resection possible. Following available data and guidelines, such evaluation should include: ECOG-scoring, cardiac risk assessment, cerebrovascular assessment, pulmonary risk assessment, including split function analysis, and additional initiation or adjustment of treatment where appropriate; in patients aged ≥ 70 years: functional scoring (IADL). Risk stratification results in three groups: patients at low risk for complications and mortality, patients at increased risk, and patients who usually are not candidates for surgical resection. Finally, in order to support autonomous decisions of patients on optimal treatment based on defined risks, physicians must be familiar with values and preferences of patients as well as their familial and social situation.

[Comprehensive Preoperative Evaluation of Patients with Lung Cancer]. / Umfassende präoperative Evaluation von Patienten mit Lungenkrebs.

Surgical resection continues to be a mainstay of curative treatment of patients with non-small cell lung cancers stages I - III and some small cell lung cancers. Reported rates of complications and mortality vary considerably. Therefore, a thorough and comprehensive preoperative evaluation of lung cancer patients is crucial in order to select appropriate surgical candidates and to determine their individual risk, including the extent of resection possible. Following available data and guidelines, such evaluation should include: ECOG-scoring, cardiac risk assessment, cerebrovascular assessment, pulmonary risk assessment, including split function analysis, and additional initiation or adjustment of treatment where appropriate; in patients aged ≥ 70 years: functional scoring (IADL).Risk stratification results in three groups: patients at low risk for complications and mortality, patients at increased risk, and patients who usually are not candidates for surgical resection.Finally, in order to support autonomous decisions of patients on optimal treatment based on defined risks, physicians must be familiar with values and preferences of patients as well as their familial and social situation.

[Complete atrioventricular block during lithium therapy within therapeutic range]. / Kompletter AV-Block unter Lithiumtherapie im therapeutischen Bereich.

HISTORY AND CLINICAL FINDINGS: A 69-year-old man came to the emergency unit because of vertigo and presyncope. A bipolar disorder - known since an age of 15 years - has been treated with 2 × 450 mg lithium and 100 mg perazine per day for several years (no other medications). With the exception of a low heart rate (36/min) clinical examination findings were unremarkable. INVESTIGATIONS: Electrocardiography revealed a permanent complete atrioventricular block with a heart rate of 36/min. Echocardiography showed a normal left ejection fraction (EF 65 %). Laboratory tests were mainly unremarkable, particularly the lithium levels (0,7 mmol/l) were within the therapeutic range. TREATMENT AND COURSE: Continuous treatment with orciprenaline stabilized the heart rate at an average of 52/min. After pacing with a provisional pacemaker a permanent pacemaker was implanted without complications, and the symptoms of vertigo and dizziness disappeared. Pacemaker checkup on the following day still showed a complete atrioventricular block with a heart rate of 28/min. CONCLUSION: Complete atrioventricular block secondary to chronic lithium therapy even in therapeutic levels is a rare complication with poor prognosis. Therefore it should be treated consequently.

[Subacute anterior myocardial infarction after mild blunt chest trauma in a 32-year-old man]. / Subakuter Vorderwandmyokardinfarkt nach mildem stumpfen Thoraxtrauma bei einem 32-jährigen Mann.

HISTORY AND CLINICAL FINDING: A 32-year-old man came to the surgical department because of persisting retrosternal pain radiating to the left side of the thorax for two days. During a move an armchair had slipped out of his hands and caused a mild blunt chest trauma. The further clinical examination findings were unremarkable. INVESTIGATIONS: Echocardiography was performed to rule out myocardial contusion. It showed a slightly reduced left-ventricular ejection fraction (EF 52 %) with akinesia of all apical segments overlapping to the septal and anterolateral wall, reaching the mid-ventricular area. The electrocardiogram (ECG) revealed a complete loss of R voltage of the anterior wall with persisting ST elevations in V4-V6.  Coronary angiography showed a short-length thrombotic occlusion of the left anterior descending artery (LAD) immediately after giving off the diagonal branch, based on a plaque-rupture. TREATMENT AND COURSE: Because of the subacute myocardial infarction in combination with a bifurcation problem a drug-eluting stent was inserted in accordance with current studies. Initial cardiac MRT showed slightly reduced left-ventricular ejection fraction (EF 50 %), while myocardial wall thickness was preserved in all segments. Four weeks later severe myocardial remodeling had caused transmural scar formation of the anterior wall which had resulted in a reduction of left-ventricular EF to 39 %. CONCLUSION: Myocardial infarction based on plaque-rupture can occur after a mild blunt chest trauma even in young patients. An early cardiological examination, at least an ECG, should be performed to avoid complications of mild, painful blunt chest trauma.