Lung transplantation following lung volume reduction surgery

Objective: Lung volume reduction surgery (LVRS) has been proposed as a poss ible alternative treatment to lung transplantation (LTX) for selected patie nts 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 LT X. 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 1 998, 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 perf ormed, in 6 patients unilateral LVRS. Subsequent LTX was performed bilatera lly in 10 patients and unilaterally in 5 patients (1 of these on the contra lateral side) to the previous LVRS. The course of lung function and clinica l outcome were analyzed in these 15 patients. Results: Mean forced expiratory volume in 1 second (FEV1) in the 15 patient s 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 FEV1, wher eas in the other 7 patients (responders) (47%) a significant improvement wa s detected (FEV1 18.1 +/- 1.8 %p and 31.9 +/- 3.7 %p, pre- and post-LVRS, r espectively, p = 0.003), but declined after 6 to 36 months. At the time of listing for LTX the mean FEV1 was 18.0 +/- 1.9 %p (no difference between th e 2 groups). LTX was performed 15.5 +/- 3.6 months (non-responders) and 25. 7 +/- 4.6 months (responders) after LVRS. FEV1 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 LTS was 20% (1 patient with primary organ fail ure, 1 patient with ongoing rejection, 1 patient with sepsis). All 3 patien ts belonged to the group of nonresponders. Two patients died 5.5 and 8.5 mo nths 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 cond itions for LTS. However, patients without functional improvement after LVRS have a high perioperative risk at subsequent LTS.