13. annual congress turkish thoracic society 5. – 9. may 2010, istanbul
DESCRIPTION
Lung Volume Reduction Surgery. 13. Annual Congress Turkish Thoracic Society 5. – 9. May 2010, Istanbul. Walter Weder MD Professor of Surgery University Hospital Zurich. COPD Function – Symptoms - HRQL. HRQL. FEV 1. RV/TLC. Chest wall Mechanics. DLCO. Physical Performance. Heart. - PowerPoint PPT PresentationTRANSCRIPT
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13. Annual Congress Turkish Thoracic Society
5. – 9. May 2010, Istanbul
Lung Volume Reduction Surgery
Walter Weder MDProfessor of Surgery
University Hospital Zurich
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COPDFunction – Symptoms - HRQL
DyspneaDyspnea
PhysicalPerformance
PhysicalPerformance
HRQLHRQL
HeartHeart
MusclesMuscles
FEV1FEV1
RV/TLCRV/TLC
DLCODLCO
GasexchangeGasexchange
PulmonaryCirculationPulmonaryCirculation
Chest wall MechanicsChest wall Mechanics
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LVRS for emphysema
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•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
Surgical Technique
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Emphysema Morphology
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Effect on FEV1 and Dyspnea
LVRS: Effect on FEV1 (% predicted)
LVRS: Effect on Dyspnea
Weder, Ann Thorac Surg 2006
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Single center studies on LVRS
Author nSurgical Mortality
FEV16 Month Duratio
nRemarks
Ciccone 2003250
4,8 % + 73 % > 5y upper lobes
Weder 2005212
2.4 % + 41 % > 5y all morphologies
Senbaklavaci 1999
91 5,5 % + 28 % diff. techniques
Brenner 2000237
+ 69 % > 2y no info
Flaherty 2001 98 5,6 + ± 50 % > 3y upper lobes
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Randomized studies on LVRS
Autor n
Surg.
Mort. Result
Geddes, 2000 48 6 % FEV1 , HRQL
Pompeo, 2000 60 6,6 % Pulmonary function
Hillerdal, 2005 106 12 % can improve health status
Miller, 2006 62 0 / 6 % FEV1 , HRQL
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The NETTNational Emphysema
Treatment TrialRationalLVRS did historically not provide convincing evidence for efficacy or reliable characterization of a subset of patients likely to benefit from surgeon.
GoalAssess 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
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LVRSSelection of Patients
• 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
• hypercapnia• pulmonary hypertension• "destroyed lung"
• paCO2 > 55 mm Hg• PAPm > 35 mm Hg
• DLCO < 20 %
Pulmonary Function≤ 45 %
> 100 %> 150%
6' w < 140 m
NETTZH
--------> 35 mm Hg--------
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Patients at high risk of death after
lung volume reduction surgeryNational 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
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Improvement in Quality of Life from the NETT
All patients
upper lobe+ high ex
Ann Thorac Surg 2006;82:431-43
upper lobe+ low ex
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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
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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
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Conclusion from the NETT
The NETT has established and demonstrated the value of LVRS in
a specific group of patients suffering from emphysema
Claude Lenfantformer director, Nat. Heart, Lung and Blood Institut NIH
Ann Thorac Surg 2006;82:385-7
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Weder et al. Ann Thorac Surg 1997
Morphologymarkedly
heterogeneousintermediatelyheterogeneous
homogeneous
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LVRV Effect on MRC
* = p < 0.05
* * * * * *
* * * ** * *
Weder Ann Thorac Surg. 2009
* = p < 0.05
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LVRS Effect on FEV1 %
* * * *
* *
*
* *
* = p < 0.05
* = p < 0.05 Weder Ann Thorac Surg. 2009
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Transplantationfree survival according to emphysema
morphology
Hazard Ratio: 0.80, 95% CI 0.66 - 0.98, p = 0.03
0 20 40 60 80 100 120 140 160
Months
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Cu
mu
lati
ve P
rop
ort
ion
Su
rviv
ing
non- heterogeneous
heterogeneous
Weder Ann Thorac Surg. 2009
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Effect of LVRS on COPD exacerbation
Washko, AJRCCM 2007
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Effect of LVRS on COPD exacerbation
Washko, AJRCCM 2007
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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
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Change in end-expiratory pulmonary capillary wedge
pressure
Criner, AJRCCM 2007
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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 medicaltreatment
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Patient selection for LVRS
The goodSymptomatic patient with marked hyperinflation, marked heterogeneity, upper lobe disease, DLCO > 20%
The badFEV1 < 20%, DLCO < 20%, homogenous disease
The uncertainMarked hyperinflation, non-marked heterogeneity, DLCO > 20%