Lung transplantation following lung volume reduction surgery

Abstract

Objective: Lung volume reduction surgery (LVRS) has been proposed as a possible alternative treatment to lung transplantation (LTX) for selected patients with end-stage emphysema. But whether LVRS is a temporary or permanent alternative to LTX is still under investigation. The aim of this study was to analyze the course of patients undergoing LVRS followed by subsequent LTX. Methods Fifteen patients (10 male, 5 female, mean age 53.3 ± 1.7 years) out of 102 patients, who underwent LVRS between September 1994 and August 1998, underwent LTX 19.6 ± 3.1 months after LVRS (range 1.7 to 37.6 months) between June 1996 and October 1998. In 9 patients bilateral LVRS was performed, in 6 patients unilateral LVRS. Subsequent LTX was performed bilaterally in 10 patients and unilaterally in 5 patients (1 of these on the contralateral side) to the previous LVRS. The course of lung function and clinical outcome were analyzed in these 15 patients. Results Mean forced expiratory volume in 1 second (FEV 1) in the 15 patients prior to LVRS was 18.3 ± 1.2% of predicted (%p) and increased to 27.0 ± 2.9 %p (best value within the first 6 months postLVRS) ( p = 0.043). In 8 of these patients (non-responders) (53%) LVRS failed to improve FEV 1, whereas in the other 7 patients (responders) (47%) a significant improvement was detected (FEV 1 18.1 ± 1.8 %p and 31.9 ± 3.7 %p, pre- and post-LVRS, respectively, p = 0.003), but declined after 6 to 36 months. At the time of listing for LTX the mean FEV 1 was 18.0 ± 1.9 %p (no difference between the 2 groups). LTX was performed 15.5 ± 3.6 months (non-responders) and 25.7 ± 4.6 months (responders) after LVRS. FEV 1 improved to 81.0 ± 5.6 %p after LTX ( p < 0.001 compared to pre-LTX). The mortality after LVRS was 0%. The 3-month mortality after LTX was 20% (1 patient with primary organ failure, 1 patient with ongoing rejection, 1 patient with sepsis). All 3 patients belonged to the group of nonresponders. Two patients died 5.5 and 8.5 months after LTX (13.3%) due to fungal infection ( Aspergillus spp.) and MRSA sepsis, respectively (1 non-responder, 1 responder). Conclusions Successful LVRS delays the need for LTX and offers better conditions for LTX. However, patients without functional improvement after LVRS have a high perioperative risk at subsequent LTX.