Thoracotomy and dyspnoea

PIG Meeting: 11th March 2021

83 year old lady with left lower lobe lesion for thoracotomy and wedge resection


  • Incidental finding of LLL lesion on CTPA. Under surveillance for one year, increasing in size. Asymptomatic.
  • Cardiothoracic surgeon strongly suspicious of malignancy
  • Long-standing dyspnoea – previous PE. Investigated but no cause identified. Intermittent in nature.
  • Spirometry: reduced FEV1 (63%) DLCO and FVC normal
  • PAF. Normal echo and Holter


  • Elderly patient without confirmed diagnosis of cancer. Should we proceed or discuss less invasive options with surgical team?
  • Dyspnoea concerning as no identified cause. Excluded significant issues such as valvular heart disease and pulmonary hypertension. Would non-invasive stress test change management – likely need expedited surgery due to cancer possibility.
  • Anticoagulation – high risk for VTE. CHADSVASC = 6


  • Thought to be little benefit in delaying to biopsy as surgeon suspicious of cancer. Will likely need to have surgery regardless.
  • Dyspnoea in patients with no respiratory cause and structurally normally heart could be caused by Atrial Fibrillation. Rate well-controlled, no need to increase dose of beta-blocker preoperatively
  • Consensus was to bridge given high risk from CHADSVASC score


  • Proceed to surgery without further investigations
  • Clexane bridging

Post-operative ICU given age, open procedure, and co-morbidities