13. Annual Congress Turkish Thoracic Society 5. – 9. May 2010, Istanbul

Lung Volume Reduction Surgery 13. Annual Congress Turkish Thoracic Society5. – 9. May 2010, Istanbul Walter Weder MD Professor of Surgery University Hospital Zurich

COPDFunction – Symptoms - HRQL HRQL FEV1 RV/TLC Chest wall Mechanics DLCO Physical Performance Heart Gasexchange Muscles Pulmonary Circulation Dyspnea

LVRS for emphysema

Surgical Technique • 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

Emphysema Morphology

Effect on FEV1 and Dyspnea LVRS: Effect on Dyspnea LVRS: Effect on FEV1 (% predicted) Weder, Ann Thorac Surg 2006

Single center studies on LVRS

Randomized studies on LVRS

The NETTNational Emphysema Treatment Trial Rational LVRS did historically not provide convincing evidence for efficacy or reliable characterization of a subset of patients likely to benefit from surgeon. Goal Assess 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 Pulmonary Function ZH NETT • 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 ≤ 45 % > 100 %> 150% 6' w < 140 m • hypercapnia • pulmonary hypertension • "destroyed lung" • paCO2 > 55 mm Hg • PAPm > 35 mm Hg • DLCO < 20 % -------- > 35 mm Hg --------

Patients at high risk of death after lung volume reduction surgery National 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 + low ex upper lobe + high ex Ann Thorac Surg 2006;82:431-43

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 Lenfant former director, Nat. Heart, Lung and Blood Institut NIH Ann Thorac Surg 2006;82:385-7

Morphology markedly heterogeneous intermediately heterogeneous homogeneous Weder et al. Ann Thorac Surg 1997

LVRV Effect on MRC * * * * * * * * * * * * * * = p < 0.05 * = p < 0.05 Weder Ann Thorac Surg. 2009

LVRS Effect on FEV1 % * * * * * * * * * * = p < 0.05 * = p < 0.05 Weder Ann Thorac Surg. 2009

Transplantationfree survival according to emphysema morphology heterogeneous non- heterogeneous Hazard Ratio: 0.80, 95% CI 0.66 - 0.98, p = 0.03 Weder Ann Thorac Surg. 2009

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 medical treatment

Patient selection for LVRS The good Symptomatic patient with marked hyperinflation, marked heterogeneity, upper lobe disease, DLCO > 20% The bad FEV1 < 20%, DLCO < 20%, homogenous disease The uncertain Marked hyperinflation, non-marked heterogeneity, DLCO > 20%

13. Annual Congress Turkish Thoracic Society 5. – 9. May 2010, Istanbul