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Native Lung Volume Reduction Surgery Relieves Functional Graft Compression in Single Lung Transplants for COPD
T. B. Reece, J. D. Mitchell*, M. Zamora, D. A. Fullerton*, J. C. Cleveland*, M. Pomerantz*, D. Lyu, F. L. Grover*, M. J. Weyant. University of Colorado, Denver, CO
Objective: Single lung transplantation (SLT) is an accepted treatment for end stage lung disease due to chronic obstructive pulmonary disease (COPD). A complication unique to SLT for COPD is graft dysfunction due to compression caused by native lung hyperinflation (NLH). This is characterized by a decline in clinical status with a decrease in measured FEV1 in the setting of radiographic evidence of graft compression. Lung volume reduction surgery (LVRS) has been proposed as a method of treatment for this phenomenon. We hypothesized that patients with graft compromise from hyperinflation of the native lung would benefit from lung volume reduction of the native lung. This study reports our experience with LVRS in patients with NLH and graft dysfunction following SLT for COPD.
Methods: The charts of all patients undergoing SLT for COPD at our institution were reviewed for LVRS of their native lung. Data regarding length of stay, surgical morbidity and mortality, overall survival, type of LVRS operation, and pulmonary function were recorded. FEV1 was used to determine overall effect of LVRS procedure by comparing FEV1 at its peak, prior to surgery, and postoperatively.
Results: Between January 1994 and December 2006, 201 SLT were performed for COPD. Ten (5%) patients developed significant graft compression based on radiologic and spirometric criteria. After excluding other causes for functional decline, these patients underwent a modified LVRS. LVRS consisted of formal lobectomy of the most diseased lobe of the native lung by CT in all patients except for one who underwent a segmentectomy and blebectomy. The procedure was performed between 12 and 142 months after lung transplant (mean 50 months). The average hospital stay was 18 days, with air leak prolonging the stay most commonly. Two of ten patients died during their hospitalization. Of the remaining 8 patients, 7 (87.5%) have demonstrated functional improvement by FEV1 to their previous baseline (Fig 1), improvement ranging from 12% to 200% (mean 57%). Improvement in FEV1 surpassed the previous peak in one patient.
Conclusions: Lung volume reduction by formal lobectomy in SLT patients with NLH and significant graft compression appears feasible. Additionally, improvements in FEV1 can be accomplished in nearly all properly selected patients. Lung volume reduction surgery should be considered in patients with declining graft function secondary to graft compression from native lung hyperinflation.
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