Fiorelli Alfonso, Santini Mario, Shah Pallav
Thoracic Surgery Unit, Università degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy.
The National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, Imperial College, London, UK.
Interact Cardiovasc Thorac Surg. 2018 Feb 1;26(2):313-318. doi: 10.1093/icvts/ivx272.
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was when can computed tomography-fissure analysis replace Chartis collateral ventilation assessment in the prediction of patients with emphysema who might benefit from endobronchial valve therapy? Twelve papers were chosen to answer the question. The authors, date, journal, country of publication and study type; patient group studied; relevant outcomes and results of these papers were tabulated. Five studies retrospectively compared the prognostic value of 2 methods. They found that when computed tomography-fissure analysis showed an intact fissure more than 95%, both methods were equivalent in correctly predicting a positive response to valve therapy. Concordant results were found in two-thirds of patients, and the additional evaluation with Chartis did not confer a significant advantage. Yet the increasing cost and time to procedure, the different ranges of Chartis findings patterns not correlated with lung volume reduction and the unfeasibility of the measurements (reported in 6-17% of the most series) due to difficult anatomy are additional limitations for its use. Conversely, in patients with fissure integrity between 75% and 90%, Chartis assessment could improve the patient selection, because the computed tomography-fissure analysis alone is unable to predict a successful treatment. In this situation, Chartis had a 31% ability to predict those patients who can be successfully treated. In BeLieVer-HIfi Study, post hoc analysis revealed that the additional use of Chartis for patient selection significantly improved outcomes. Similarly, STELVIO, LIVE and IMPACT studies, where only patients with complete fissure and negative Chartis measurement were treated, showed significant benefits after valve treatment. Finally, in patients with fissure integrity below 75%, the negative predictive value for lobar atelectasis is 100%. Thus, in these patients, it could be futile even considering a Chartis assessment.
根据结构化方案撰写了一篇胸外科最佳证据主题文章。所探讨的问题是，在预测哪些肺气肿患者可能从支气管内瓣膜治疗中获益时，计算机断层扫描-肺裂分析何时能够取代Chartis侧支通气评估？选择了12篇论文来回答该问题。将这些论文的作者、日期、期刊、出版国家和研究类型；所研究的患者群体；相关结局和结果制成表格。5项研究回顾性比较了两种方法的预后价值。他们发现，当计算机断层扫描-肺裂分析显示肺裂完整率超过95%时，两种方法在正确预测瓣膜治疗阳性反应方面相当。在三分之二的患者中发现了一致的结果，并且使用Chartis进行额外评估并没有带来显著优势。然而，操作成本和时间增加、Chartis检查结果模式的不同范围与肺容积减少无关，以及由于解剖结构困难导致测量不可行（在大多数系列报道中为6%-17%）是其使用的额外限制。相反，在肺裂完整率为75%至90%的患者中，Chartis评估可以改善患者选择，因为仅计算机断层扫描-肺裂分析无法预测治疗是否成功。在这种情况下，Chartis有31%的能力预测哪些患者可以得到成功治疗。在BeLieVer-HIfi研究中，事后分析显示，额外使用Chartis进行患者选择可显著改善结局。同样，在STELVIO、LIVE和IMPACT研究中，仅对肺裂完整且Chartis测量为阴性的患者进行治疗，瓣膜治疗后显示出显著益处。最后，在肺裂完整率低于75%的患者中，叶状肺不张的阴性预测值为100%。因此，对于这些患者，即使考虑进行Chartis评估也可能徒劳无功。
