Effect of Lung Volume Reduction Surgery on Resting Pulmonary Hemodynamics in Severe Emphysema

Criner, Gerard J.; Scharf, Steven M.; Falk, Jeremy A.; Gaughan, John; Sternberg, Alice L.; Patel, Namrata; Fessler, H; Minai, Omar A.; Fishman, Alfred P.

doi:10.1164/rccm.200608-1114oc

Cited by 84 publications

(50 citation statements)

References 33 publications

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“…In addition to its immediate effects, an increased RV stroke volume induced by LVRS persists until at least 3 months after surgery [8]. LVRS has been shown to lower Ppcw without a change in pulmonary artery pressure [26][27][28]. Therefore the lowered wedge pressure may be due to reduced intrathoracic pressures.…”

Section: Discussionmentioning

confidence: 99%

Increased oxygen pulse after lung volume reduction surgery is associated with reduced dynamic hyperinflation

et al. 2012

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Stroke volume augmentation during exercise is limited in chronic obstructive pulmonary disease patients because of decreased preload from dynamic hyperinflation (DH). We hypothesised that oxygen pulse and pulse pressure (PP) improve following lung volume reduction surgery (LVRS), and the magnitude of improvement correlates with reduction in DH.We compared 16 emphysema patients undergoing LVRS with six emphysema patients not undergoing LVRS. Oxygen pulse and PP were calculated from maximal cardiopulmonary exercise tests at baseline and 6 months. End-expiratory lung volume (EELV)/total lung capacity (TLC) represented DH. Comparisons were made between baseline and 6 months at metabolic isotimes (per cent maximal carbon dioxide production (V9CO 2 ,max)).At baseline, the LVRS group was older with higher forced expiratory volume in 1 s, but had similar hyperinflation to the non-LVRS group. At 6 months, oxygen pulse (50%, 75%, and 100% V9CO 2 ,max) and PP (50% and 75% V9CO 2 ,max) increased in the LVRS, but not in the non-LVRS group. Baseline functional residual capacity/TLC inversely correlated with resting oxygen pulse (r5 -0.449, p50.04). Decreased EELV/TLC correlated with increased oxygen pulse at 75% (r5 -0.487, p50.02) and 100% V9CO 2 ,max (r5 -0.548, p50.008).LVRS led to increased oxygen pulse and PP during exercise at metabolic isotimes 6 months following surgery. Reductions in DH correlated with increases in oxygen pulse during exercise. Reducing lung volume may improve stroke volume response to exercise by decreasing DH.KEYWORDS: Cardiopulmonary interactions, chronic obstructive pulmonary disease, exercise, physiology C hronic obstructive pulmonary disease (COPD) patients have impaired exercise tolerance, which limits their quality of life. While ventilatory limitations, including dynamic hyperinflation (DH), are the main cause of exercise intolerance in this population [1], causes for this impairment are probably multifactorial [2]. Impairment in cardiac mechanics in COPD may be one of the most important contributing factors. Stroke volume is reduced in COPD, especially during exercise [3]. Decreased stroke volume is due to increased intrathoracic pressures and decreased cardiac right-sided filling [4][5][6].Along with its beneficial effects on mortality [7] and pulmonary function [8], lung volume reduction surgery (LVRS) improves exercise capacity by altering lung mechanics [7,9,10]. LVRS also favourably affects stroke volume, both at rest [8] and during exercise [11]. Increased right ventricular stroke volume post-LVRS has been reported to correlate with decreased resting hyperinflation [11]. The effect of DH on cardiac function during exercise in COPD, however, is unknown.To investigate the effect of DH and LVRS on cardiac performance during exercise, we retrospectively analysed data from emphysema patients who had cardiopulmonary exercise tests (CPETs) before and after LVRS, and compared their changes with those who did not undergo LVRS. We hypothesised that LVRS would lead to an increase in no...

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Section: Discussionmentioning

confidence: 99%

Increased oxygen pulse after lung volume reduction surgery is associated with reduced dynamic hyperinflation

et al. 2012

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“…Early studies have shown conflicting results, with increases in Ppa after LVRS in one study [130] but not in others [127,128]. A recent study as part of the National Emphysema Treatment Trial has shown no significant differences in terms of P pa and PVR, 6 months after medical treatment or LVRS [129].…”

Section: Lvrs and Lung Transplantationmentioning

confidence: 98%

“…There have been few studies on pulmonary haemodynamics before and after LVRS [127][128][129]. LVRS may have adverse effects on pulmonary haemodynamics owing to the reduction of the vascular bed after the resection of lung tissue.…”

Section: Lvrs and Lung Transplantationmentioning

confidence: 99%

Pulmonary hypertension in COPD

Chaouat¹,

Naeije²,

Weitzenblum³

2008

Eur Respir J

538

418

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Mild-to-moderate pulmonary hypertension is a common complication of chronic obstructive pulmonary disease (COPD); such a complication is associated with increased risks of exacerbation and decreased survival. Pulmonary hypertension usually worsens during exercise, sleep and exacerbation. Pulmonary vascular remodelling in COPD is the main cause of increase in pulmonary artery pressure and is thought to result from the combined effects of hypoxia, inflammation and loss of capillaries in severe emphysema.A small proportion of COPD patients may present with ''out-of-proportion'' pulmonary hypertension, defined by a mean pulmonary artery pressure .35-40 mmHg (normal is no more than 20 mmHg) and a relatively preserved lung function (with low to normal arterial carbon dioxide tension) that cannot explain prominent dyspnoea and fatigue. The prevalence of out-ofproportion pulmonary hypertension in COPD is estimated to be very close to the prevalence of idiopathic pulmonary arterial hypertension.Cor pulmonale, defined as right ventricular hypertrophy and dilatation secondary to pulmonary hypertension caused by respiratory disorders, is common. More studies are needed to define the contribution of cor pulmonale to decreased exercise capacity in COPD. These studies should include improved imaging techniques and biomarkers, such as the B-type natriuretic peptide and exercise testing protocols with gas exchange measurements.The effects of drugs used in pulmonary arterial hypertension should be tested in chronic obstructive pulmonary disease patients with severe pulmonary hypertension. In the meantime, the treatment of cor pulmonale in chronic obstructive pulmonary disease continues to rest on supplemental oxygen and a variety of measures aimed at the relief of airway obstruction.

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“…Fifty-five of 110 patients underwent baseline right heart catheterization postrehabilitation and then 6 months after randomization to medical therapy or LVRS (25). Baseline demographics and lung function were similar between groups and moderate pulmonary hypertension was present at baseline (mean Ppa, 24.8 6 4.99 mm Hg).…”

Section: Effects Of Lvrs On Pulmonary Hemodynamicsmentioning

confidence: 99%

The National Emphysema Treatment Trial (NETT)

Criner

Cordova

Sternberg

et al. 2011

Am J Respir Crit Care Med

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177

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Substantial information regarding the role of lung volume reduction surgery (LVRS) in severe emphysema emanates from the National Emphysema Treatment Trial (NETT). The NETT was not a crossover trial and therefore was able to examine the effects of optimal medical management and LVRS on short-and long-term survival, as well as lung function, exercise performance, and quality of life. The NETT generated multiple insights into the preoperative, perioperative, and postoperative management of patients undergoing thoracotomy; described pain control techniques that were safe and effective; and emphasized the need to address nonpulmonary issues to optimize surgical outcomes. After the NETT, newer investigation has focused on bronchoscopic endobronchial interventions and other techniques less invasive than LVRS to achieve lung reduction. In this review, we summarize what we currently know about the role of LVRS in the treatment of severe emphysema as a result of insights gained from the NETT and provide a brief review of the newer techniques of lung volume reduction.Keywords: emphysema; COPD; lung volume reduction surgery Much of the information regarding lung volume reduction surgery (LVRS) emanates from the National Emphysema Treatment Trial (NETT). NETT was a multicenter prospective randomized controlled trial that compared optimal medical treatment, including pulmonary rehabilitation, with optimal medical treatment plus LVRS (1). NETT was not a crossover trial and thus was able to examine the effects of optimal medical management and LVRS on short-and long-term survival, as well as lung function, exercise performance, and quality of life.After NETT, newer investigation has focused on bronchoscopic endobronchial interventions and other techniques less invasive than LVRS to achieve lung reduction (2). Moreover, new data have surfaced regarding the effects of LVRS on ameliorating the manifestations of systemic inflammation (3), the cardiovascular ramifications of hyperinflation (4), and improved radiological techniques that identify optimal LVRS candidates (5).In this review, we summarize what we currently know about LVRS as a result of NETT in the treatment of severe emphysema and provide a brief review of lung volume reduction techniques. LVRS: BACKGROUNDData regarding LVRS before NETT mainly consisted of uncontrolled, single-center case series characterized by small patient numbers and substantial variability in selection criteria, surgical technique, duration of follow-up, and definitions of complications and outcomes (6-15).NETT was a randomized, controlled, multicenter, long-term trial that examined the effects of LVRS on the primary end points of survival and maximal exercise performance and the secondary end points of lung function, patient symptoms, and quality of life in contrast to medical therapy (16).In 2003, NETT first reported the effects of LVRS on survival and maximal exercise capacity in 1,218 patients with emphysema who were randomized to LVRS or medical treatment between January 1998 and July 2002 an...

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Effect of Lung Volume Reduction Surgery on Resting Pulmonary Hemodynamics in Severe Emphysema

Cited by 84 publications

References 33 publications

Increased oxygen pulse after lung volume reduction surgery is associated with reduced dynamic hyperinflation

Increased oxygen pulse after lung volume reduction surgery is associated with reduced dynamic hyperinflation

Pulmonary hypertension in COPD

The National Emphysema Treatment Trial (NETT)

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