13. annual congress turkish thoracic society 5. – 9. may 2010, istanbul

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%