PURPOSE: When patients choose lung volume reduction surgery (LVRS) as a bridge to lung transplantation (LTx), they accept an increased risk of both LVRS-related and additional morbidity associated with LTx after LVRS in exchange for bridging the time to LTx. This study evaluates the risk-benefit tradeoffs in LVRS as a bridge to LTx for end-stage emphysema in a large-volume lung transplant center in the US.
METHODS: Twenty-five patients out of 177 patients who underwent LTx for end-stage emphysema had prior LVRS between 2002 and 2009 (LVRS group). We compared in-hospital morbidity, mid-term graft quality and long-term outcomes of LVRS group patients to a matched cohort (age-, gender-, procedure-, and transplant time-matched) to assess the possible added post-transplant morbidity and mortality.
RESULTS: LVRS group had 22 bilateral and 3 unilateral procedures and their subsequent LTx was performed 22.9±15.9 months (median, 25.5 months; range, 14 to 62 months). Postoperative respiratory complications and renal dysfunction requiring dialysis were higher in LVRS group whereas long-term survival was not significantly different (5-year survival, 59.7% in LVRS group versus 66.2%). Pulmonary functional improvement 6 months after LTx was significantly worse in LVRS group in view of FEV1 increase (22.3% vs. 54.2%, p<0.05). LVRS group had a higher incidence of primary graft dysfunction following LTx. Multivariate analysis showed CPB usage and pulmonary hypertension being the significant predictors for adverse early outcomes (p<0.05). Notably, there was a significantly higher 30-day mortality following LTx in the patients who developed greater than mild pulmonary hypertension (transpulmonary gradient pressure above 30 mmHg) after LVRS.
CONCLUSIONS: LVRS can bridge the time to transplantation in appropriately selected patients without significantly increasing post-transplant morbidity or mortality; however, LVRS can yield additional morbidity associated with LTx and it should be noted that high-risk patients exist in prior LVRS patients who result in higher mortality following LTx.
CLINICAL IMPLICATIONS: In very selected candidates, LVRS can be beneficial as either an alternative or a bridge to lung transplant for end-stage emphysema; however, our data suggest that patients who develop significant pulmonary hypertension after LVRS should be considered as high-risk candidates for subsequent lung transplantation.
DISCLOSURE: The following authors have nothing to disclose: Norihisa Shigemura, Sebastien Gilbert, Jay Bhama, Aditya Bansal, Pramod Bonde, Christian Bermudez, Cynthia Gries, Maria Crespo, Bruce Johnson, Joseph Pilewski, James Luketich, Yoshiya Toyoda
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