Bavaria J E, Pochettino A, Kotloff R M, Rosengard B R, Wahl P M, Roberts J R, Palevsky H I, Kaiser L R
Department of Cardiothoracic Surgery, University of Pennsylvania Medical Center, Philadelphia 19104, USA.
J Thorac Cardiovasc Surg. 1998 Jan;115(1):9-17; discussion 17-8. doi: 10.1016/s0022-5223(98)70437-4.
End-stage chronic obstructive pulmonary disease has traditionally been treated with lung transplantation. For 2 years, our lung transplantation program has placed patients with appropriate criteria for lung transplantation and volume reduction into a prospective management algorithm. These patients are offered the lung volume reduction option as a "bridge" to "extend" the eventual time to transplantation. We examine the results of this pilot program.
From October 11, 1993, to April 17, 1997, 31 patients were evaluated for lung transplantation who also had physiologic criteria for volume reduction (forced expiratory volume in 1 second < or = 25%; residual volume > 200%; significant ventilation/perfusion heterogeneity). All patients completed 6 weeks of pulmonary rehabilitation and then had baseline pulmonary function and 6-minute walk tests. These patients were then offered volume reduction as a "bridge" and were simultaneously listed for transplantation. Postoperatively, these 31 patients were then divided into two groups: Those with satisfactory results at 4 to 6 months after volume reduction and those with unsatisfactory results. Volume reduction was performed through a video thoracic approach in 87% of the patients and bilateral median sternotomy in the remaining 13%. The condition of the patients was monitored after the operation with repeated pulmonary function tests and 6-minute walk tests at 3-month intervals.
Twenty-four of 31 patients (77.4%) had primary success (at 4 to 6 months) results after lung volume reduction and 7 patients (22.6%) had primary failure, including 1 patient who died in the perioperative period (3.2%). Four patients (16.7%) from the primary success cohort had significant deterioration in their pulmonary function during intermediate-term follow-up and were then reconsidered for lung transplantation. Two of them have subsequently undergone transplantation with good postoperative pulmonary function results. Interestingly, three patients had alpha 1-antitrypsin deficiency; two had a poor outcome of lung volume reduction and primary failure.
Lung volume reduction in these patients is safe. Seventy-seven percent of otherwise suitable candidates for lung transplantation achieved initial good results from volume reduction and were deactivated from the list (placed on status 7). Most patients entering our prospective management algorithm have either significantly delayed or completely avoided lung transplantation after volume reduction. Lung volume reduction has substantially affected the practice, timing, and selection of patients for lung transplantation. Our waiting list now has a reduced percentage of patients with a diagnosis of chronic obstructive pulmonary disease compared with 3 years ago. Our experience suggests that lung volume reduction may be limited as a "bridge" in alpha 1-antitrypsin deficiency.
终末期慢性阻塞性肺疾病传统上采用肺移植治疗。两年来，我们的肺移植项目将符合肺移植适当标准且适合进行肺减容术的患者纳入了一项前瞻性管理算法。这些患者被提供肺减容术这一选择，作为“桥梁”来“延长”最终的移植时间。我们对这个试点项目的结果进行了研究。
从1993年10月11日至1997年4月17日，对31例接受肺移植评估的患者进行了评估，这些患者同时也符合肺减容术的生理标准（第1秒用力呼气量≤25%；残气量>200%；显著的通气/灌注不均一性）。所有患者均完成了6周的肺康复治疗，然后进行了基线肺功能和6分钟步行试验。这些患者随后被提供肺减容术作为“桥梁”，并同时被列入移植名单。术后，这31例患者被分为两组：肺减容术后4至6个月结果满意的患者和结果不满意的患者。87%的患者通过胸腔镜手术进行肺减容术，其余13%的患者通过双侧正中胸骨切开术进行。术后通过定期进行肺功能测试和每3个月进行一次6分钟步行试验来监测患者的情况。
31例患者中有24例（77.4%）在肺减容术后取得了初步成功（4至6个月时），7例患者（22.6%）出现初步失败，其中1例患者在围手术期死亡（3.2%）。在中期随访期间，24例初步成功组中的4例患者（16.7%）肺功能出现显著恶化，随后被重新考虑进行肺移植。其中2例随后接受了移植，术后肺功能良好。有趣的是，3例患者存在α1-抗胰蛋白酶缺乏症；其中2例肺减容术效果不佳并出现初步失败。
这些患者进行肺减容术是安全的。77%原本适合肺移植的患者通过肺减容术取得了初步良好效果，并从名单中除名（处于7级状态）。大多数进入我们前瞻性管理算法的患者在肺减容术后要么显著推迟了肺移植时间，要么完全避免了肺移植。肺减容术对肺移植患者的治疗实践、时机选择和患者选择产生了重大影响。与3年前相比，我们目前的等待名单中诊断为慢性阻塞性肺疾病的患者比例有所下降。我们的经验表明，在α1-抗胰蛋白酶缺乏症患者中，肺减容术作为“桥梁”的作用可能有限。
