LUNG-VOLUME REDUCTION OR LUNG TRANSPLANTATION FOR END-STAGE PULMONARY-EMPHYSEMA

Objective: As the waiting period for lung transplant (LT) candidates w ith end-stage pulmonary emphysema (COPD) continues to increase, there is a need for alternative treatments to reduce the morbidity and morta lity associated with COPD. We hypothesized that lung reduction (LR) ma y avoid the need for subsequent LT in patients on the waiting list tha t are also candidates for LR. Methods: From July 1994 to December 1995 , 20 patients received LR as alternative to LT. The average age was 58 +/- 7 years; 11 were males. Eighteen patients had primary COPD and tw o had alpha-1 antitrypsin deficiency. Eighteen LRs were thoracoscopic (two bilateral and 16 unilateral) and two were done through a median s ternotomy. Results: At a follow-up of 32 +/- 4 months, 19 patients are alive (19/20 = 95%). Fifteen patients (15/20 = 75%) are currently off the LT list and doing well: FEVI is 40 +/- 18% predicted at 2 years c ompared with 22.7 +/- 6% before LR (P < 0.001); FVC is 84 +/- 13% at 2 years compared with 55 +/- 7% (P < 0.001) and the RV is 145 +/- 59% c ompared with 270 +/- 58% (P < 0.001). One patient (5%) required extra- corporeal membrane oxygenation (ECMO) after LR to the contralateral si de of the first procedure and subsequently died. Two patients (10%) ar e currently listed for LT because of persistent symptoms. One patient (5%) in whom deterioration was secondary to exposure to toxic fumes, u nderwent successful LT, One patient (5%) is doing well from the pulmon ary standpoint but is being worked up for new severe coronary artery d isease (CAD). The freedom from LT is 95% (19/20) and the freedom from repeat LR is 85% (17/20). Conclusions: LR has the potential to offer a n effective palliative alternative to LT in 75% of selected patients u p to 32 months of follow-up. Widespread use of bilateral LR is anticip ated to further improve the results. (C) 1998 Elsevier Science B.V. Al l rights reserved.