Lung Transplantation after Endoscopic Lung Volume Reduction

Abstract

Background: Endoscopic lung volume reduction (ELVR) has become an established treatment option in selected patients with end-stage lung emphysema. ELVR, however, does not always prevent disease progression, and patients may inevitably be considered for lung transplantation. Objectives: Currently, limited data exist regarding the impact of preceding ELVR on lung transplantation outcomes. Methods: A retrospective, single-center analysis of lung transplantation (LTx) waiting list candidates, who had previously undergone ELVR for emphysema between 2010 and 2014, was performed. Outcomes were compared to matched (1:2) controls who underwent LTx for emphysema without previous ELVR. The 12-month survival after LTx represented the primary end point. Results: In total 23/693 (3%) patients listed for LTx between January 2010 and May 2014 had undergone ELVR, of whom 20/23 (87%) proceeded to LTx (ELVR group). Forty matched non-ELVR emphysema patients acted as controls. Bronchiectasis on CT prior to LTx was more evident in ELVR patients [11/20 (55%) vs. 12/40 (30%); p = 0.04] as well as airway colonization after LTx [10/20 (50%) vs. 6/40 (15%); p = 0.004]. Among ELVR patients, the most prevalent colonizing organism was Stenotrophomonas maltophilia (4/10 patients, 40%). No significant differences were observed in LTx waiting list time, duration of LTx procedure, ventilatory support, ICU stay after LTx or time to hospital discharge. One ELVR patient (5%) died 189 days after LTx from pneumonia, compared to 1 non-ELVR patient (3%) who died after 269 days (p = 0.61). Conclusions: Previous ELVR treatment was not associated with differing outcomes following LTx. Increased bacterial colonization rates were evident and warrant further investigation.

Endoscopic Lung Volume Reduction Using Endobronchial Valves in Patients with Severe Emphysema and Very Low FEV₁

“…Most patients do not qualify for transplantation, and the demand for organs exceeds their availability by far. As these patients usually remain symptomatic despite optimal conservative treatment, there is a great need for therapies that actually improve the burden of symptoms [18]. …”

New bacterial growth in bronchial secretions after bronchoscopic valve implantation

“…10 Very little data are available regarding the association between bacterial growth after valve implantation and procedure-related COPD exacerbation. 11 This retrospective analysis investigates the bacterial growth with examination of the bronchial secretions for presence or change of bacterial growth before and after valve implantation.…”

“…However, there were no different outcomes after LTX in terms of LTX waiting list time, duration of LTX procedure, ventilatory support, intensive care unit stay after LTX, or time to hospital discharge, comparing patients with previous ELVR to non-ELVR patients. 11 It is recommended that patients receive a prophylactic antibiotic therapy as well as short courses of oral steroids after valve implantation, to prevent bronchitis and exacerbations. 30 The patients in the analyzed cohort also received a prophylactic antibiotic therapy with Cefuroxim after valve implantation, for 5 days, but no oral steroids routinely.…”

Consideraciones en la derivación y selección de candidatos a trasplante pulmonar

“…el estudio más reciente que incluyó a 238 pacientes trasplantados con cirugía torácica previa, encontró una mayor incidencia de parálisis frénica, reexploración por sangrado e insuficiencia renal al compararlos con pacientes sin cirugía torácica previa; siendo la pleurodesis química y el bypass prolongado predictores de mortalidad 21 . la cirugía de reducción de volumen pulmonar (elvr) que se realiza en pacientes seleccionados con ePoC puede generar adherencias pleurales que conlleva un mayor riesgo hemorragia, reexploración por sangrado e insuficiencia renal, cuando se realiza el trasplante 22 . Por lo anterior, se recomiendan procedimientos broncoscópicos de reducción de volumen pulmonar como etapa previa en pacientes que cumplan con criterios establecidos y derivar a trasplante cuando este procedimiento falle o no sea factible de realizar.…”