13. Annual Congress Turkish Thoracic Society
5. – 9. May 2010, Istanbul
Lung Volume Reduction Surgery
Walter Weder MDProfessor of Surgery
University Hospital Zurich
COPDFunction – Symptoms - HRQL
DyspneaDyspnea
PhysicalPerformance
PhysicalPerformance
HRQLHRQL
HeartHeart
MusclesMuscles
FEV1FEV1
RV/TLCRV/TLC
DLCODLCO
GasexchangeGasexchange
PulmonaryCirculationPulmonaryCirculation
Chest wall MechanicsChest wall Mechanics
LVRS for emphysema
•Resection planned by chest CT Morphology („target areas“)
•Thorascopic wedge-resection (endoscop. linear stapler) of most impaired areas
•Usually bilateral procedure
•Smoker‘s emphysema: „hockey stick“ Resection of the upper lobe
•Lower lobe (a1-AT-deficiency): Resection of basal LL segments
Surgical Technique
Emphysema Morphology
Effect on FEV1 and Dyspnea
LVRS: Effect on FEV1 (% predicted)
LVRS: Effect on Dyspnea
Weder, Ann Thorac Surg 2006
Single center studies on LVRS
Author nSurgical Mortality
FEV16 Month Duratio
nRemarks
Ciccone 2003250
4,8 % + 73 % > 5y upper lobes
Weder 2005212
2.4 % + 41 % > 5y all morphologies
Senbaklavaci 1999
91 5,5 % + 28 % diff. techniques
Brenner 2000237
+ 69 % > 2y no info
Flaherty 2001 98 5,6 + ± 50 % > 3y upper lobes
Randomized studies on LVRS
Autor n
Surg.
Mort. Result
Geddes, 2000 48 6 % FEV1 , HRQL
Pompeo, 2000 60 6,6 % Pulmonary function
Hillerdal, 2005 106 12 % can improve health status
Miller, 2006 62 0 / 6 % FEV1 , HRQL
The NETTNational Emphysema
Treatment TrialRationalLVRS did historically not provide convincing evidence for efficacy or reliable characterization of a subset of patients likely to benefit from surgeon.
GoalAssess the safety and efficacy of LVRS in comparison with medical therapy in patients with moderate to severe emphysema
J Thorac cardiovasc surg 1999; 118:518 - 28
LVRSSelection of Patients
• COPD with emphysema with severe irreversible obstruction to airflow
• marked hyperinflation of the lung
• impaired exercise performance
• FEV1 < 35 % pred.
• TLC > 110 % pred. RV > 200%
• 12' walking < 600 m
• hypercapnia• pulmonary hypertension• "destroyed lung"
• paCO2 > 55 mm Hg• PAPm > 35 mm Hg
• DLCO < 20 %
Pulmonary Function≤ 45 %
> 100 %> 150%
6' w < 140 m
NETTZH
--------> 35 mm Hg--------
Patients at high risk of death after
lung volume reduction surgeryNational Emphysema Treatment Trial Research Group
FEV1 < 20 % pred. and homogeneous distribution of emphysema or DLCO < 20 % pred.
N Engl J Med, Vol. 345, No. 15 – Okt. 11, 2001
Improvement in Quality of Life from the NETT
All patients
upper lobe+ high ex
Ann Thorac Surg 2006;82:431-43
upper lobe+ low ex
Survival LVRS vs Medical Therapy from the NETT
All patients
upper lobe+ low ex
upper lobe+ high ex
Ann Thorac Surg 2006;82:431-43
Improvement in Quality of Life from the NETT
Non upper lobe+ high ex
Non upper lobe+ low ex
Ann Thorac Surg 2006;82:431-43
Conclusion from the NETT
The NETT has established and demonstrated the value of LVRS in
a specific group of patients suffering from emphysema
Claude Lenfantformer director, Nat. Heart, Lung and Blood Institut NIH
Ann Thorac Surg 2006;82:385-7
Weder et al. Ann Thorac Surg 1997
Morphologymarkedly
heterogeneousintermediatelyheterogeneous
homogeneous
LVRV Effect on MRC
* = p < 0.05
* * * * * *
* * * ** * *
Weder Ann Thorac Surg. 2009
* = p < 0.05
LVRS Effect on FEV1 %
* * * *
* *
*
* *
* = p < 0.05
* = p < 0.05 Weder Ann Thorac Surg. 2009
Transplantationfree survival according to emphysema
morphology
Hazard Ratio: 0.80, 95% CI 0.66 - 0.98, p = 0.03
0 20 40 60 80 100 120 140 160
Months
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Cu
mu
lati
ve P
rop
ort
ion
Su
rviv
ing
non- heterogeneous
heterogeneous
Weder Ann Thorac Surg. 2009
Effect of LVRS on COPD exacerbation
Washko, AJRCCM 2007
Effect of LVRS on COPD exacerbation
Washko, AJRCCM 2007
Effect of LVRS on pulmonary hemodynamics
• In comparison to medical therapy, LVRS was not associated with an increase in PA pressure
Criner, AJ RCCM, 2007
• LVRS did not change pulmonary hemodynamics significantly
Thurnheer, EJ CTS 1998
Change in end-expiratory pulmonary capillary wedge
pressure
Criner, AJRCCM 2007
Before the NETT
LVRS improves dyspnea, pulmonary function work of breathing and quality of life in selected patients
After the NETT
Additionally it improves survival, COPD exa-cerbations and PCWP compared to medicaltreatment
Patient selection for LVRS
The goodSymptomatic patient with marked hyperinflation, marked heterogeneity, upper lobe disease, DLCO > 20%
The badFEV1 < 20%, DLCO < 20%, homogenous disease
The uncertainMarked hyperinflation, non-marked heterogeneity, DLCO > 20%
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