Thymectomy in myasthenia gravis: Proposal for a predictive score of postoperative myasthenic crisis

Giovanni Leuzzi, Elisa Meacci, Giacomo Cusumano, Alfredo Cesario, Marco Chiappetta, Valentina Dall'armi, Amelia Evoli, Roberta Costa, Filippo Lococo, Paolo Primieri, Stefano Margaritora, Pierluigi Granone

Research output: Contribution to journalArticle

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Abstract

OBJECTIVES: Thymectomy plays an important role in patients with myasthenia gravis (MG). This study aimed to explore predictors of postoperative myasthenic crisis (POMC) after thymectomy and to define a predictive score of respiratory failure. METHODS: The clinical data of 177 patients with MG undergoing thymectomy from January 1995 to December 2011 were retrospectively reviewed. The following factors were analysed in relation to the occurrence of myasthenic crisis: gender, age, body mass index (BMI), anti-acetylcholine receptor-antibody level, bulbar symptoms, comorbidities, duration of symptoms, Osserman-stage, Myasthenia Gravis Foundation of America (MGFA) stage, history of myasthenic crisis, use of immoglobulins or plasmapheresis, kind of therapy, spirometric and blood gas parameters, histology, kind of surgery, non-myasthenic complications and duration of intubation. RESULTS: Twenty-two patients experienced postoperative respiratory failure after thymectomy. Univariate analysis revealed a correlation with age >60 years (odds ratio (OR) = 1.79, 95% confidence interval (CI) = 1.04-6.78; P = 0.040); Osserman-stage (IIB- OR = 5.16, 95% CI = 1.10-24.18; P = 0.037, III-IV- OR = 8.75, 95% CI = 1.53-50.05; P = 0.015); bulbar symptoms (OR = 7.42, 95% CI = 1.67-32.84; P = 0.008); BMI >28 (OR = 3.99, 95% CI = 1.58-10.03; P = 0.003); preoperative plasmapheresis (OR = 2.97, 95% CI = 1.18-14.04; P = 0.021); duration of symptoms >2 years (OR = 4.00, 95% CI = 1.09-14.762; P = 0.036); extended surgery (OR = 2.52, 95% CI = 1.02-6.22; P = 0.045); lung (OR = 4.05, 95% CI = 1.44-11.42; P = 0.008), pericardial (OR = 3.78, 95% CI = 1.45-9.82; P = 0.006) or pleural resection (OR = 3.23, 95% CI = 1.30-8.03; P = 0.012); Vital Capacity % 2 >40 mmHg (OR = 3.76, 95% CI = 1.12-12.68; P = 0.032). Multivariate logistic regression analysis showed that Osserman-stage (IIB- OR = 5.69, 95% CI = 1.09-29.69; P = 0.039 (III-IV- OR = 11.33, 95% CI = 1.67-76.72; P = 0.013), BMI >28 (OR = 3.65, 95% CI = 1.10-12.15; P = 0.035), history of myasthenic crisis (OR = 24.10, 95% CI = 2.34-248.04; P = 0.007), duration of symptoms >2 years (OR = 5.94, 95% CI = 1.12-31.48; P = 0.036) and lung resection (OR = 8.48, 95% CI = 2.18-32.97; P = 0.002) independently predict POMC. Excluding history of preoperative myasthenic crisis (statistically associated with Osserman-stage), we built a scoring system according to the OR of Osserman-stage (I-IIA, IIB, III-IV), BMI (2 years) and association with a pulmonary resection. This model helped in creating four classes with increasing risk of respiratory failure (Group I, 6%; Group II, 10%; Group III, 25%; Group IV, 50%). CONCLUSIONS: Our model facilitates the stratification of patient risk and prediction of the occurrence of POMC. Moreover, it could help to guide the anaesthesiologist's decision on the duration of intubation. Further studies based on larger series are needed to confirm these preliminary data.

Original languageEnglish
Article numberezt641
JournalEuropean Journal of Cardio-thoracic Surgery
Volume45
Issue number4
DOIs
Publication statusPublished - 2014

Fingerprint

Thymectomy
Myasthenia Gravis
Muscle Weakness
Odds Ratio
Confidence Intervals
Body Mass Index
Respiratory Insufficiency
Plasmapheresis
Intubation
Lung

Keywords

  • Intubation
  • Myasthenia gravis
  • Myasthenic crisis
  • Scoring system

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery
  • Pulmonary and Respiratory Medicine

Cite this

Thymectomy in myasthenia gravis : Proposal for a predictive score of postoperative myasthenic crisis. / Leuzzi, Giovanni; Meacci, Elisa; Cusumano, Giacomo; Cesario, Alfredo; Chiappetta, Marco; Dall'armi, Valentina; Evoli, Amelia; Costa, Roberta; Lococo, Filippo; Primieri, Paolo; Margaritora, Stefano; Granone, Pierluigi.

In: European Journal of Cardio-thoracic Surgery, Vol. 45, No. 4, ezt641, 2014.

Research output: Contribution to journalArticle

Leuzzi, G, Meacci, E, Cusumano, G, Cesario, A, Chiappetta, M, Dall'armi, V, Evoli, A, Costa, R, Lococo, F, Primieri, P, Margaritora, S & Granone, P 2014, 'Thymectomy in myasthenia gravis: Proposal for a predictive score of postoperative myasthenic crisis', European Journal of Cardio-thoracic Surgery, vol. 45, no. 4, ezt641. https://doi.org/10.1093/ejcts/ezt641
Leuzzi, Giovanni ; Meacci, Elisa ; Cusumano, Giacomo ; Cesario, Alfredo ; Chiappetta, Marco ; Dall'armi, Valentina ; Evoli, Amelia ; Costa, Roberta ; Lococo, Filippo ; Primieri, Paolo ; Margaritora, Stefano ; Granone, Pierluigi. / Thymectomy in myasthenia gravis : Proposal for a predictive score of postoperative myasthenic crisis. In: European Journal of Cardio-thoracic Surgery. 2014 ; Vol. 45, No. 4.
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title = "Thymectomy in myasthenia gravis: Proposal for a predictive score of postoperative myasthenic crisis",
abstract = "OBJECTIVES: Thymectomy plays an important role in patients with myasthenia gravis (MG). This study aimed to explore predictors of postoperative myasthenic crisis (POMC) after thymectomy and to define a predictive score of respiratory failure. METHODS: The clinical data of 177 patients with MG undergoing thymectomy from January 1995 to December 2011 were retrospectively reviewed. The following factors were analysed in relation to the occurrence of myasthenic crisis: gender, age, body mass index (BMI), anti-acetylcholine receptor-antibody level, bulbar symptoms, comorbidities, duration of symptoms, Osserman-stage, Myasthenia Gravis Foundation of America (MGFA) stage, history of myasthenic crisis, use of immoglobulins or plasmapheresis, kind of therapy, spirometric and blood gas parameters, histology, kind of surgery, non-myasthenic complications and duration of intubation. RESULTS: Twenty-two patients experienced postoperative respiratory failure after thymectomy. Univariate analysis revealed a correlation with age >60 years (odds ratio (OR) = 1.79, 95{\%} confidence interval (CI) = 1.04-6.78; P = 0.040); Osserman-stage (IIB- OR = 5.16, 95{\%} CI = 1.10-24.18; P = 0.037, III-IV- OR = 8.75, 95{\%} CI = 1.53-50.05; P = 0.015); bulbar symptoms (OR = 7.42, 95{\%} CI = 1.67-32.84; P = 0.008); BMI >28 (OR = 3.99, 95{\%} CI = 1.58-10.03; P = 0.003); preoperative plasmapheresis (OR = 2.97, 95{\%} CI = 1.18-14.04; P = 0.021); duration of symptoms >2 years (OR = 4.00, 95{\%} CI = 1.09-14.762; P = 0.036); extended surgery (OR = 2.52, 95{\%} CI = 1.02-6.22; P = 0.045); lung (OR = 4.05, 95{\%} CI = 1.44-11.42; P = 0.008), pericardial (OR = 3.78, 95{\%} CI = 1.45-9.82; P = 0.006) or pleural resection (OR = 3.23, 95{\%} CI = 1.30-8.03; P = 0.012); Vital Capacity {\%} 2 >40 mmHg (OR = 3.76, 95{\%} CI = 1.12-12.68; P = 0.032). Multivariate logistic regression analysis showed that Osserman-stage (IIB- OR = 5.69, 95{\%} CI = 1.09-29.69; P = 0.039 (III-IV- OR = 11.33, 95{\%} CI = 1.67-76.72; P = 0.013), BMI >28 (OR = 3.65, 95{\%} CI = 1.10-12.15; P = 0.035), history of myasthenic crisis (OR = 24.10, 95{\%} CI = 2.34-248.04; P = 0.007), duration of symptoms >2 years (OR = 5.94, 95{\%} CI = 1.12-31.48; P = 0.036) and lung resection (OR = 8.48, 95{\%} CI = 2.18-32.97; P = 0.002) independently predict POMC. Excluding history of preoperative myasthenic crisis (statistically associated with Osserman-stage), we built a scoring system according to the OR of Osserman-stage (I-IIA, IIB, III-IV), BMI (2 years) and association with a pulmonary resection. This model helped in creating four classes with increasing risk of respiratory failure (Group I, 6{\%}; Group II, 10{\%}; Group III, 25{\%}; Group IV, 50{\%}). CONCLUSIONS: Our model facilitates the stratification of patient risk and prediction of the occurrence of POMC. Moreover, it could help to guide the anaesthesiologist's decision on the duration of intubation. Further studies based on larger series are needed to confirm these preliminary data.",
keywords = "Intubation, Myasthenia gravis, Myasthenic crisis, Scoring system",
author = "Giovanni Leuzzi and Elisa Meacci and Giacomo Cusumano and Alfredo Cesario and Marco Chiappetta and Valentina Dall'armi and Amelia Evoli and Roberta Costa and Filippo Lococo and Paolo Primieri and Stefano Margaritora and Pierluigi Granone",
year = "2014",
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TY - JOUR

T1 - Thymectomy in myasthenia gravis

T2 - Proposal for a predictive score of postoperative myasthenic crisis

AU - Leuzzi, Giovanni

AU - Meacci, Elisa

AU - Cusumano, Giacomo

AU - Cesario, Alfredo

AU - Chiappetta, Marco

AU - Dall'armi, Valentina

AU - Evoli, Amelia

AU - Costa, Roberta

AU - Lococo, Filippo

AU - Primieri, Paolo

AU - Margaritora, Stefano

AU - Granone, Pierluigi

PY - 2014

Y1 - 2014

N2 - OBJECTIVES: Thymectomy plays an important role in patients with myasthenia gravis (MG). This study aimed to explore predictors of postoperative myasthenic crisis (POMC) after thymectomy and to define a predictive score of respiratory failure. METHODS: The clinical data of 177 patients with MG undergoing thymectomy from January 1995 to December 2011 were retrospectively reviewed. The following factors were analysed in relation to the occurrence of myasthenic crisis: gender, age, body mass index (BMI), anti-acetylcholine receptor-antibody level, bulbar symptoms, comorbidities, duration of symptoms, Osserman-stage, Myasthenia Gravis Foundation of America (MGFA) stage, history of myasthenic crisis, use of immoglobulins or plasmapheresis, kind of therapy, spirometric and blood gas parameters, histology, kind of surgery, non-myasthenic complications and duration of intubation. RESULTS: Twenty-two patients experienced postoperative respiratory failure after thymectomy. Univariate analysis revealed a correlation with age >60 years (odds ratio (OR) = 1.79, 95% confidence interval (CI) = 1.04-6.78; P = 0.040); Osserman-stage (IIB- OR = 5.16, 95% CI = 1.10-24.18; P = 0.037, III-IV- OR = 8.75, 95% CI = 1.53-50.05; P = 0.015); bulbar symptoms (OR = 7.42, 95% CI = 1.67-32.84; P = 0.008); BMI >28 (OR = 3.99, 95% CI = 1.58-10.03; P = 0.003); preoperative plasmapheresis (OR = 2.97, 95% CI = 1.18-14.04; P = 0.021); duration of symptoms >2 years (OR = 4.00, 95% CI = 1.09-14.762; P = 0.036); extended surgery (OR = 2.52, 95% CI = 1.02-6.22; P = 0.045); lung (OR = 4.05, 95% CI = 1.44-11.42; P = 0.008), pericardial (OR = 3.78, 95% CI = 1.45-9.82; P = 0.006) or pleural resection (OR = 3.23, 95% CI = 1.30-8.03; P = 0.012); Vital Capacity % 2 >40 mmHg (OR = 3.76, 95% CI = 1.12-12.68; P = 0.032). Multivariate logistic regression analysis showed that Osserman-stage (IIB- OR = 5.69, 95% CI = 1.09-29.69; P = 0.039 (III-IV- OR = 11.33, 95% CI = 1.67-76.72; P = 0.013), BMI >28 (OR = 3.65, 95% CI = 1.10-12.15; P = 0.035), history of myasthenic crisis (OR = 24.10, 95% CI = 2.34-248.04; P = 0.007), duration of symptoms >2 years (OR = 5.94, 95% CI = 1.12-31.48; P = 0.036) and lung resection (OR = 8.48, 95% CI = 2.18-32.97; P = 0.002) independently predict POMC. Excluding history of preoperative myasthenic crisis (statistically associated with Osserman-stage), we built a scoring system according to the OR of Osserman-stage (I-IIA, IIB, III-IV), BMI (2 years) and association with a pulmonary resection. This model helped in creating four classes with increasing risk of respiratory failure (Group I, 6%; Group II, 10%; Group III, 25%; Group IV, 50%). CONCLUSIONS: Our model facilitates the stratification of patient risk and prediction of the occurrence of POMC. Moreover, it could help to guide the anaesthesiologist's decision on the duration of intubation. Further studies based on larger series are needed to confirm these preliminary data.

AB - OBJECTIVES: Thymectomy plays an important role in patients with myasthenia gravis (MG). This study aimed to explore predictors of postoperative myasthenic crisis (POMC) after thymectomy and to define a predictive score of respiratory failure. METHODS: The clinical data of 177 patients with MG undergoing thymectomy from January 1995 to December 2011 were retrospectively reviewed. The following factors were analysed in relation to the occurrence of myasthenic crisis: gender, age, body mass index (BMI), anti-acetylcholine receptor-antibody level, bulbar symptoms, comorbidities, duration of symptoms, Osserman-stage, Myasthenia Gravis Foundation of America (MGFA) stage, history of myasthenic crisis, use of immoglobulins or plasmapheresis, kind of therapy, spirometric and blood gas parameters, histology, kind of surgery, non-myasthenic complications and duration of intubation. RESULTS: Twenty-two patients experienced postoperative respiratory failure after thymectomy. Univariate analysis revealed a correlation with age >60 years (odds ratio (OR) = 1.79, 95% confidence interval (CI) = 1.04-6.78; P = 0.040); Osserman-stage (IIB- OR = 5.16, 95% CI = 1.10-24.18; P = 0.037, III-IV- OR = 8.75, 95% CI = 1.53-50.05; P = 0.015); bulbar symptoms (OR = 7.42, 95% CI = 1.67-32.84; P = 0.008); BMI >28 (OR = 3.99, 95% CI = 1.58-10.03; P = 0.003); preoperative plasmapheresis (OR = 2.97, 95% CI = 1.18-14.04; P = 0.021); duration of symptoms >2 years (OR = 4.00, 95% CI = 1.09-14.762; P = 0.036); extended surgery (OR = 2.52, 95% CI = 1.02-6.22; P = 0.045); lung (OR = 4.05, 95% CI = 1.44-11.42; P = 0.008), pericardial (OR = 3.78, 95% CI = 1.45-9.82; P = 0.006) or pleural resection (OR = 3.23, 95% CI = 1.30-8.03; P = 0.012); Vital Capacity % 2 >40 mmHg (OR = 3.76, 95% CI = 1.12-12.68; P = 0.032). Multivariate logistic regression analysis showed that Osserman-stage (IIB- OR = 5.69, 95% CI = 1.09-29.69; P = 0.039 (III-IV- OR = 11.33, 95% CI = 1.67-76.72; P = 0.013), BMI >28 (OR = 3.65, 95% CI = 1.10-12.15; P = 0.035), history of myasthenic crisis (OR = 24.10, 95% CI = 2.34-248.04; P = 0.007), duration of symptoms >2 years (OR = 5.94, 95% CI = 1.12-31.48; P = 0.036) and lung resection (OR = 8.48, 95% CI = 2.18-32.97; P = 0.002) independently predict POMC. Excluding history of preoperative myasthenic crisis (statistically associated with Osserman-stage), we built a scoring system according to the OR of Osserman-stage (I-IIA, IIB, III-IV), BMI (2 years) and association with a pulmonary resection. This model helped in creating four classes with increasing risk of respiratory failure (Group I, 6%; Group II, 10%; Group III, 25%; Group IV, 50%). CONCLUSIONS: Our model facilitates the stratification of patient risk and prediction of the occurrence of POMC. Moreover, it could help to guide the anaesthesiologist's decision on the duration of intubation. Further studies based on larger series are needed to confirm these preliminary data.

KW - Intubation

KW - Myasthenia gravis

KW - Myasthenic crisis

KW - Scoring system

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