EFFECT OF VOLUME REDUCTION ON LUNG-TRANSPLANT TIMING AND SELECTION FOR CHRONIC OBSTRUCTIVE PULMONARY-DISEASE

Background: End-stage chronic obstructive pulmonary disease has tradit ionally been treated with lung transplantation. For 2 years, our lung transplantation program has placed patients with appropriate criteria for lung transplantation and volume reduction into a prospective manag ement algorithm, These patients are offered the lung volume reduction option as a ''bridge'' to ''extend'' the eventual time to transplantat ion. We examine the results of this pilot program, Methods: From Octob er 11, 1993, to April 17, 1997, 31 patients were evaluated for lung tr ansplantation who also had physiologic criteria for volume reduction ( forced expiratory volume in 1 second less than or equal to 25%; residu al volume > 200%; significant ventilation/perfusion heterogeneity), Al l patients completed 6 weeks of pulmonary rehabilitation and then had baseline pulmonary function and 6-minute walk tests, These patients we re then offered volume reduction as a ''bridge'' and were simultaneous ly listed for transplantation. Postoperatively, these 31 patients were then divided into two groups: Those with satisfactory results at 4 to 6 months after volume reduction and those with unsatisfactory results , Volume reduction was performed through a video thoracic approach in 87% of the patients and bilateral median sternotomy in the remaining 1 3%, The condition of the patients was monitored after the operation wi th repeated pulmonary function tests and 6-minute walk tests at 3-mont h intervals, Results: Twenty-four of 31 patients (77.4%) had primary s uccess (at 4 to 6 months) results after lung volume reduction and 7 pa tients (22.6%) had primary failure, including 1 patient who died in th e perioperative period (3.2%), Four patients (16.7%) from the primary success cohort had significant deterioration in their pulmonary functi on during intermediate-term follow-up and were then reconsidered for l ung transplantation. Two of them have subsequently undergone transplan tation with good postoperative pulmonary function results, Interesting ly, three patients had alpha(1)-antitrypsin deficiency; two had a poor outcome of lung volume reduction and primary failure, Conclusions: Lu ng volume reduction in these patients is safe, Seventy-seven percent o f otherwise suitable candidates for lung transplantation achieved init ial good results from volume reduction and were deactivated from the l ist (placed on status 7). Most patients entering our prospective manag ement algorithm have either significantly delayed or completely avoide d lung transplantation after volume reduction, Lung volume reduction h as substantially affected the practice, timing, and selection of patie nts for lung transplantation. Our waiting list now has a reduced perce ntage of patients with a diagnosis of chronic obstructive pulmonary di sease compared with 3 years ago. Our experience suggests that lung vol ume reduction may be limited as a ''bridge'' in alpha(1)-antitrypsin d eficiency.