Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
Ann Thorac Surg. 2022 Feb;113(2):491-497. doi: 10.1016/j.athoracsur.2021.02.009. Epub 2021 Feb 17.
Lung volume reduction surgery (LVRS) is treatment option for chronic obstructive pulmonary disease, the second most common indication for lung transplantation (LTx) in the United States. Lung volume reduction surgery before LTx is controversial. Single-institution studies report contradicting results, and the impact of undergoing LVRS before LTx on outcomes after LTx is unclear.
We reviewed the United Network for Organ Sharing database for all adults (aged more than 18 years) who underwent first-time LTx for chronic obstructive pulmonary disease in the lung allocation score era. We used patient demographic and clinical characteristics and lung allocation score to propensity match patients who did and patients who did not undergo LVRS before LTx. The primary exposure was prior LVRS. The primary outcome was graft failure after LTx. Unadjusted Kaplan-Meier and adjusted Cox proportional hazards models were used to assess outcomes.
A total of 4905 patients with chronic obstructive pulmonary disease underwent LTx between May 2005 and March 2017. Of them, 107 patients (2.2%) underwent LVRS before LTx. Propensity matching generated 212 matches (106 LVRS+LTx, and 106 LTx only). Median survival was significantly longer in the LTx only cohort (6.5 vs 3.4 years, P = .034). Lung volume reduction surgery before lung transplantation was associated with significantly increased risk of graft failure after lung transplant (hazard ratio 1.72; 95% confidence interval, 1.13 to 2.60; P = .01).
In this national, propensity-matched analysis of LVRS before LTx, we show that LVRS is associated with a significantly increased risk of graft failure. Patients who undergo LVRS and remain in need of LTx should be carefully assessed and followed postoperatively.
肺减容手术（LVRS）是治疗慢性阻塞性肺疾病的一种方法，是美国肺移植（LTx）的第二大常见适应证。LTx 前进行 LVRS 存在争议。单中心研究报告结果相互矛盾，LTx 前进行 LVRS 对 LTx 后结局的影响尚不清楚。
我们检索了器官共享联合网络数据库中所有在肺分配评分时代因慢性阻塞性肺疾病接受首次 LTx 的成年人（年龄大于 18 岁）的数据。我们使用患者的人口统计学和临床特征以及肺分配评分对接受和未接受 LTx 前 LVRS 的患者进行倾向评分匹配。主要暴露因素是 LTx 前的 LVRS。主要结局是 LTx 后的移植物失败。我们使用未调整的 Kaplan-Meier 法和调整后的 Cox 比例风险模型评估结局。
共有 4905 例慢性阻塞性肺疾病患者在 2005 年 5 月至 2017 年 3 月期间接受了 LTx。其中 107 例（2.2%）在 LTx 前接受了 LVRS。倾向评分匹配生成了 212 对（106 例 LVRS+LTx，106 例仅 LTx）。仅接受 LTx 的队列中位生存时间明显更长（6.5 年比 3.4 年，P=0.034）。LTx 前进行 LVRS 与 LTx 后移植物失功的风险显著增加相关（风险比 1.72；95%置信区间，1.13 至 2.60；P=0.01）。
在这项关于 LTx 前进行 LVRS 的全国性、倾向评分匹配分析中，我们发现 LVRS 与移植物失功的风险显著增加相关。接受 LVRS 且仍需要 LTx 的患者应在术后进行仔细评估和随访。
