Department of Thoracic Surgery and Oncology, Division of Thoracic Surgery and Service of Physiopathology, National Cancer Institute, Naples, Italy; ; Division of Respiratory Physiopathology, Monaldi Hospital, Naples, Italy.
J Thorac Dis. 2013 Feb;5(1):12-8. doi: 10.3978/j.issn.2072-1439.2012.12.04.
Maximal oxygen consumption (VO(2)max) is considered a decisive test for risk prediction in patients with borderline cardiopulmonary reserve. Guidelines have adopted decreasing VO(2)max cut-off values to define operability within acceptable mortality and morbidity limits. We wanted to investigate how the adoption of decreasing VO(2)max cut-off-values assessment contributed to better select lung surgery candidates.
One hundred and nineteen consecutive surgical candidates have been prospectively analyzed as a sample population. Preoperative work-up included spirometry and transfer factor (DLco); irrespective of the spirometric values, these patients were subjected to VO(2)max assessment. Surgical eligibility was decided by the same surgeon throughout the series. In the postoperative period, overall mortality and the occurrence of any, major or minor complications was recorded and graded according to the Common Terminology Criteria for Adverse Events v.4.3.
Three arbitrary cut-offs were introduced at 15, 14 and 12 mL(.)kg(-1) (.)min(-1). Notably, 15 and 12 mL(.)kg(-1) (.)min(-1) correlated with percentage VO(2)max values of 50% and 35% of predicted (P<0.0001 and 0.0079), respectively. Accordingly, the patients were subdivided into groups in which the prevalence of postoperative morbidity was recorded. The groups were homogeneous as to age, BMI, preoperative absolute and percentage FEV1 and DLco. In the Cox proportionate-hazards multivariate analysis, VO(2)max less than 35% (P=0.0017) and CTCAE >2 (P=0.0457) emerged as significant predictors of survival after surgery. Conversely on logistic regression analysis, age over 70 years (P=0.03) and pneumonectomy (P=0.001), but not VO(2)max cut-off values, were significant predictors of major (CTCAE >2) morbidity.
Since VO(2)max is increasingly used to contribute to risk prediction for the individual patient, surgeons need to be advised that the concept of a definitive, generalized cut-off value for VO(2)max is probably a contradiction in terms. Patient-specific VO(2)max values are more likely to contribute to risk assessment since they may reflect the primarily affected component among the determinants of maximal oxygen consumption. Whether patient-specific VO(2)max should be routinely used by surgeons to define operability for borderline patients needs further evaluation.
最大摄氧量（VO₂max）被认为是预测心肺储备边缘患者风险的决定性试验。指南采用降低 VO₂max 截止值来定义在可接受的死亡率和发病率限制内的可操作性。我们想研究采用降低 VO₂max 截止值评估标准如何有助于更好地选择肺手术候选人。
119 例连续手术候选者被前瞻性分析为样本人群。术前检查包括肺量计和转移因子（DLco）；无论肺量计值如何，这些患者均接受 VO₂max 评估。整个系列中，由同一位外科医生决定手术的适应证。术后记录总死亡率和任何、主要或次要并发症的发生情况，并根据通用不良事件术语标准 4.3 进行分级。
引入了三个任意截止值，分别为 15、14 和 12 mL(.)kg(-1)（.)min(-1)。值得注意的是，15 和 12 mL(.)kg(-1)（.)min(-1)分别与预测值的 50%和 35%的 VO₂max 值相关（P<0.0001 和 0.0079）。因此，根据术后发病率记录将患者分为不同的组。这些组在年龄、BMI、术前绝对和百分比 FEV1 和 DLco 方面是同质的。在 Cox 比例风险多变量分析中，VO₂max 小于 35%（P=0.0017）和 CTCAE >2（P=0.0457）是术后生存的显著预测因素。相反，在逻辑回归分析中，年龄大于 70 岁（P=0.03）和全肺切除术（P=0.001），但不是 VO₂max 截止值，是主要（CTCAE >2）发病率的显著预测因素。
由于 VO₂max 越来越多地用于帮助预测个体患者的风险，因此外科医生需要注意，VO₂max 的确定、通用截止值的概念可能是矛盾的。特定于患者的 VO₂max 值更有可能有助于风险评估，因为它们可能反映了最大摄氧量决定因素中受影响最大的成分。特定于患者的 VO₂max 是否应常规由外科医生用于定义边缘患者的可操作性，需要进一步评估。
