Two years' outcome of lung volume reduction surgery in different morphologic emphysema types

BACKGROUND: Lung volume reduction surgery (LVRS) improves dyspnea, pulmonary function, and quality of life in selected patients with severe emphysema. We investigated the role of emphysema morphology in 37 patients as an outcome predictor for up to 2 years after operation. METHODS: Patients selected for bilateral thoracoscopic LVRS were divided, according to a simplified emphysema morphology classification, into three groups (homogeneous, moderately heterogeneous, and markedly heterogeneous) based on a preoperative chest computed tomogram. Pulmonary function, walking distance, and dyspnea were assessed. RESULTS: Functional improvement after LVRS was best in markedly heterogeneous emphysema with an increase from preoperative forced expiratory volume in 1 second of 31% +/- 2% (mean +/- standard error of the mean) to 52% +/- 4% of predicted postoperatively. It was significantly higher than in homogeneous emphysema (from 26% +/- 1% to 38% +/- 2% predicted) and in intermediately heterogeneous emphysema (from 29% +/- 2% to 44% +/- 45% predicted). At 24 months postoperatively, forced expiratory volume in 1 second and dyspnea score continued to be significantly better than preoperative levels in all three morphologic groups. The survival rate was highest in patients with markedly heterogeneous emphysema. CONCLUSIONS: Functional and subjective improvements were maintained after LVRS for at least 24 months in patients with heterogeneous or homogeneous emphysema type.     

Survival after unilateral versus bilateral lung volume reduction surgery for emphysema

OBJECTIVE: Bilateral staple lung volume reduction surgery (LVRS) immediately improves pulmonary function and dyspnea symptoms in patients with advanced heterogeneous emphysema to a greater degree than do unilateral procedures. However, the long-term outcome after these surgical procedures needs to be critically evaluated. We compare 2-year survival of patients who underwent unilateral versus bilateral video-assisted LVRS in a large cohort treated by a single surgical group. METHODS: The cases of all 260 patients who underwent video-assisted thoracoscopic stapled LVRS from April 1994 to March 1996 were analyzed to compare results after unilateral versus bilateral procedures. Overall survival was calculated by Kaplan-Meier methods; Cox proportional hazard methods were used to adjust for patient heterogeneity and baseline differences between groups. RESULTS: Overall survival at 2 years was 86.4% (95% CI 80. 9%-91.8%) after bilateral LVRS versus 72.6% (95% CI 64.2%-81.2%) after unilateral LVRS (P =.001 for overall survival comparison). Improved survival after bilateral LVRS was seen among high- and low-risk subgroups as well. Average follow-up time was 28.5 months (range, 6 days to 46.6 months) for the bilateral LVRS group and 29.3 months (range, 6 days to 45.0 months) for the unilateral LVRS patients. CONCLUSIONS: Comparison of unilateral versus bilateral thoracoscopic LVRS procedures for the treatment of emphysema reveals that bilateral LVRS by video-assisted thoracoscopy resulted in better overall survival at 2-year follow-up than did unilateral LVRS. This survival study, together with other studies demonstrating improved lung function after bilateral LVRS, suggests that bilateral surgery appears to be the procedure of choice for patients undergoing LVRS for most eligible patients with severe heterogeneous emphysema.     

Outcome after unilateral lung volume reduction surgery in patients with severe emphysema.

OBJECTIVE: Bilateral lung volume reduction surgery (LVRS) has emerged as a palliative treatment option in patients with severe pulmonary emphysema. However, it is not known if a sustained functional improvement can be obtained using an unilateral approach. METHODS: We hypothesized that a palliative effect can also be obtained by unilateral LVRS and prospectively assessed lung function, walking distance, and dyspnea before and 3, 6, 12, 18, 24 and 36 months after unilateral LVRS. RESULTS: Twenty-eight patients were operated by the use of video-assisted thoracoscopic surgery (VATS) with a mean follow-up of 16.5 months (range 3-36 months). Forced expiratory volume in 1 s (FEV1) was significantly improved up to 3 months (1007+/-432 compared to 1184+/-499 ml, P<0.001), residual volume up to 24 months (4154+/-1126 compared to 3390+/-914 ml, P<0.01), dyspnea up to 12 months (modified Borg dyspnea scale 6.6+/-1.8 compared to 3.9+/-1.8, P=0.01) and walking distance up to 24 months (343+/-107 compared to 467+/-77 m, P<0.05) after unilateral LVRS compared to preoperative values. Overall, 25 of 28 patients reported a subjective benefit after unilateral LVRS. There was no 30-day mortality. Only two patients required surgery on the contralateral side after 4.5 and 6 months, respectively, both suffering from alpha-1-antitrypsin deficiency. CONCLUSIONS: Unilateral LVRS by the use of VATS results in a sustained beneficial effect, improving walking distance and dyspnea for up to 24 months in patients with severe emphysema. The preservation of the contralateral side for future intervention if required renders unilateral LVRS an attractive concept in this difficult palliative situation.     

电视胸腔镜辅助小切口行双侧肺减容术治疗重度肺气肿

目的:评价电视胸腔镜辅助小切口行双侧肺减容术治疗重度肺气肿的疗效,并总结围术期的处理经验。方法:回顾分析2006年以来为18例重度肺气肿患者实施肺减容术的临床资料,对比分析手术前后肺功能指标和动脉血氧分压的变化。结果:本组无手术死亡病例,2例合并急性呼吸衰竭。术后随访半年,平均第1秒用力呼气量增加39.2%,用力肺活量增加20.1%,残气量下降26.5%,肺总量下降23.1%,动脉血氧分压平均上升15.1%,与术前相比差异有统计学意义(P<0.05)。结论:电视胸腔镜辅助小切口行双侧肺减容术是经济有效的治疗方法,能明显改善重度肺气肿患者的临床症状和生理状况,增加活动能力。     

肺减容手术(LVRS)治疗重度阻塞性肺气肿

目的探讨重度肺气肿采用肺减容术的适应症、围手术期准备及手术方法。方法对6例重度肺气肿患者施行肺容积减少术，其中间期双侧2例，单侧4例。为控制肺切面漏气，缝合时衬以牛心包片。本组切除一侧肺容积25％—30％。结果无手术死亡。术后2例并发急性呼吸衰竭，经积极抢救处理而治愈。术后随诊3—12个月，肺功能有明显改善，PaO2均有显著上升，PaCO2亦有所下降。结论肺减容术是治疗严重肺气肿的有价值的治疗方法之一。     

Lung Volume Reduction Surgery for Chronic Obstructive Pulmonary Disease: Where Do We Stand?

Lung volume reduction surgery (LVRS) is a promising new treatment for selected patients with moderate to severe symptoms of emphysema. Medical management, including pulmonary rehabilitation, has been shown to reduce oxygen requirements during exercise and probably to reduce hospitalization for patients with severe emphysema, but it does not improve pulmonary function. By improving the elastic recoil of the lung, LVRS is the first treatment to demonstrate substantial improvement in pulmonary function and quality of life for selected patients with emphysema. The most important selection factor for LVRS is the presence of a heterogeneous pattern of emphysema. Because it is found in only 20% of patients with emphysema, only a small number of patients are candidates for the procedure. Published reports indicate that the optimal operative technique appears to be a bilateral staple operation during a single anesthetic. This procedure offers a 68% chance of oxygen independence, 85% chance of prednisone independence, and 60% to 70% improvement in pulmonary function for patients with an upper lobe distribution of emphysema. The long-term benefits of the procedure are currently unknown, so several randomized, prospective studies are now comparing LVRS with maximal medical management.     

肺减容术治疗重度肺气肿临床探讨

目的 研究肺减容术对重度肺气肿的手术适应证和临床疗效。方法 选择２０例重度肺气肿患者,经胸骨正中劈开切口或电视辅助胸腔镜途径,用直线切割缝合器或Ｅｎｄｏ ＧＩＡ,切除因过度膨胀而破坏的、无功能肺组织。每侧肺切除其容量的２０％￣３０％。结果术后呼吸困难明显减轻或消失;９５％患者呼吸困难指数从４￣５级转变为１￣２级。肺功能１秒时间肺活量（ＦＥＶ１）增加４１．４％,残气量（ＲＶ）和肺总量（ＴＬＣ）分别     

重症慢性阻塞性肺疾病合并肺大疱的微创治疗

目的探讨重症慢性阻塞性肺疾病（chronic obstructive pulmonary disease,COPD）合并肺大疱行胸腔镜肺大疱切除术、肺减容术（1ung volume reduction surgery,LVRS）的可行性。方法2007年6月一2012年4月,对12例重症COPD（合并Ⅱ型呼吸衰竭）的肺大疱行胸腔镜肺大疱切除、LVRS。术前、术中、术后充分做好肺保护,术中用垫有奈维材料的内镜切割缝合器（Endo．GIA）切除肺大疱和肺的边缘组织。比较患者手术前后血气分析及肺功能改善情况。结果全组无死亡,未出现持续性漏气和严重肺部感染,术后2天内均脱离呼吸机。术后呼吸困难症状明显改善,英国医学研究委员会（medical research council,MRC）呼吸困难量表分级由Ⅳ级降为Ⅱ级3例,Ⅲ级9例。术后3个月复查肺功能第1秒用力呼气容积（FEV1）、FEV,占预计值百分比（FEV1％）及血气分析氧分压（PaO2）升高,二氧化碳分压（PaCO2）降低（P〈0．01）。结论对于肺功能较差的重症COPD合并肺大疱患者可行胸腔镜肺大疱切除、肺减容术,手术治疗能有效改善肺功能。     

Causes of allograft dysfunction after single lung transplantation for emphysema: extrinsic restriction versus intrinsic obstruction. Brigham and Women's Hospital Lung Transplantation Group.

BACKGROUND: A subset of patients with emphysema who have undergone single lung transplantation (SLT) may subsequently present with dyspnea, worsening airways obstruction, hypoxemia, and progressive chronic native lung hyperinflation. The leading cause of late allograft dysfunction is bronchiolitis obliterans syndrome (BOS). However, extrinsic restriction manifests with a similar clinical presentation and is an additional mechanism to consider. We describe the use of the inspiratory lung resistance (RLi) to distinguish a decline in respiratory status due predominantly to either extrinsic restriction or BOS. METHODS: We studied five patients who underwent SLT for emphysema between 1992 and 1995, in whom the diagnoses of BOS and extrinsic restriction were subsequently entertained. Forced expiratory volume in 1 second (FEV1), RLi, static lung compliance, elastic recoil pressure at total lung capacity (TLC), and the slope of the maximum flow static recoil (MFSR) plot were measured. RESULTS: All patients had severe airflow obstruction, with mean FEV1 0.98 +/- 0.24 liter (26 +/- 5% predicted), elevated static lung compliance, reduced elastic recoil pressure at TLC, and reduced slope of the MFSR plot. Three patients had "low" RLi (9.3-12.8 cm H20/L/sec). Obstruction was attributed predominantly to extrinsic restriction. These patients underwent lung volume reduction surgery (LVRS) on the native lung; improvements in pulmonary mechanics were observed at 6 months. In contrast, two patients had markedly elevated RLi (17.3 and 17.4 cm H2O/L/sec). Obstruction was attributed predominantly to intrinsic airway disease from BOS that was subsequently documented at autopsy. CONCLUSIONS: The RLi appears to be a useful adjunct to the clinical history in distinguishing a decline in respiratory status due predominantly to either BOS or extrinsic restriction in patients who have undergone SLT for emphysema. Determination of the mechanism of allograft dysfunction may allow the selection of an appropriate subset of patients who would benefit from LVRS.     

Results of lung volume reduction surgery for emphysema

LVRS provides an exciting opportunity for palliation of symptoms and improvement in quality of life for patients who have severe end-stage emphysema. Because no medical therapy has been able to improve pulmonary function or reverse the inexorable decline of breathless patients who have emphysema, this opportunity to improve lung function and quality of life is one of the most innovative additions to thoracic surgery since the first successful lung transplant procedure 20 years ago. Although initial short-term, case-controlled surgeries were criticized because of incomplete and short follow-up care, substantial long-term data now exist to support the use of LVRS for select patients who have severe emphysema. Patients who have upper lobe predominant disease or low exercise capacity are more likely to have a benefit in exercise capacity and quality of life after LVRS. Selected patients who have upper lobe emphysema and poor exercise capacity are also more likely to have improved survival after LVRS. The individual contributions by the large number of investigators pioneering LVRS development, along with the collective contributions of the NETT investigators, have propelled the knowledge surrounding LVRS far beyond that of any similar new technology or procedure in its adolescence.     

Is there a role for therapeutic lobectomy for emphysema?

OBJECTIVE: The feasibility of performing a standard lobectomy in patients with non-small cell lung cancer (NSCLC) and severe heterogeneous emphysema whose respiratory reserve is outside standard operability guidelines has been described [Edwards JG, Duthie DJR, Waller DA. Lobar volume reduction surgery: a method of increasing the lung cancer resection rate in patients with emphysema. Thorax 2001;56:791-5; Korst RJ, Ginsberg RJ, Ailawadi M, Bains MS, Downey RJ, Rusch V, Stover D. Lobectomy improves ventilatory function in selected patients with severe COPD. Ann Thorac Surg 1998;66:898-902; Carretta A, Zannini P, Puglisi A, Chiesa G, Vanzulli A, Bianchi A, Fumagalli A, Bianco S. Improvement in pulmonary function after lobectomy for non-small cell lung cancer in emphysematous patients. Eur J Cardiothorac Surg 1999;15(5):602-7]. Postoperative lung function was better than predicted, attributable to the therapeutic benefit of deflation of the hemithorax. Our aim was to determine whether the physiological benefits of this approach were superior to conventional non-anatomical lung volume reduction surgery (LVRS) in similar patients. METHODS: A retrospective review of a single surgeon's experience identified 34 consecutive patients who underwent upper lobectomy for completely resected stage I-II NSCLC, and who had severe heterogeneous emphysema of apical distribution with a predicted postoperative FEV1 of less than 40%. Their perioperative characteristics, postoperative spirometry and survival of these cases were compared to 46 similar patients who underwent unilateral upper lobe LVRS during the same period. RESULTS: Data expressed as median (range). LVRS patients were significantly younger (59 years [39-70] vs 67 years [48-79] p<0.001), with more severe airflow obstruction (FEV(1) %pred 24 [12-60] vs 44 [17-54] p<0.001) and more heterogenous disease ('Q' score 4 [0.5-11.5] vs 7 [1-13] p=0.001) than the lobectomy group. No significant difference was found in median survival (88 vs 53 months, p=0.06). Lobectomy patients had a shorter air leak duration (5 days [2-36] vs 9 days [1-40], p=0.02) and hospital stay (8 days [3-63] vs 13 days [6-90] p=0.01). A significant correlation was found between pre-operative Q score and percentage improvement in FEV1 (r=-0.33, p=0.02). CONCLUSIONS: Lobectomy for lung cancer in patients in severe heterogenous chronic obstructive pulmonary disease is associated with similar improvement in airflow obstruction as conventional LVRS, but is associated with a shorter postoperative course. Lobectomy may therefore offer a therapeutic alternative to conventional LVRS in a selected population.     

Combined video-assisted thoracoscopic lung volume reduction surgery and lobectomy in a high-risk patient

Nonsmall cell lung cancer often occurs in patients with severe emphysema. Lobectomy in these patients is often contraindicated due to extensive parenchymal destruction and subsequent pulmonary insufficiency. Video-assisted thoracoscopic lobectomy has been described as a less morbid procedure in high-risk patients. Lung volume reduction surgery has been shown to improve pulmonary function in selected patients with emphysema. We describe the successful combination of lobectomy and lung volume reduction surgery (LVRS) with a video-assisted thoracoscopic (VATS) approach in a high-risk patient with Stage I nonsmall cell lung cancer.     

Long-term results of lung volume reduction surgery.

OBJECTIVE: Lung volume reduction surgery (LVRS) is effective in the short and intermediate term for the improvement of pulmonary function and subjective symptoms in selected patients with advanced emphysema. The purpose of this study was to examine the long-term functional results of LVRS and to investigate which subgroups would benefit in terms of long-term survival. METHODS: All records of the patients who underwent LVRS between 1994 and, 1998 at our hospital were reviewed. RESULTS: Eighty-eight consecutive patients underwent LVRS during the period. There were 62 men and 26 women with an average age of 56.1 years (range 34-72 years). Eleven patients with alpha1-antitrypsin deficiency were included. The perioperative mortality rate (<90 days) was 2.3% (n=2). Total lung capacity (7.5+/-0.3 l) and residual volume (4.8+/-0.3 l) at 3 years remained lower than baseline (9.2+/-0.2 l, 6.5+/-0.2 l, each) (P<0.001). The mean forced expiratory volume in 1 s (FEV(1)) at 3 years (0.86+/-0.08 l) was higher than baseline (0.78+/-0.02 l), but the difference did not reach statistical significance. The FEV(1) of the patients with alpha1-antitrypsin deficiency and of those with respiratory bronchiolitis returned to baseline at one year after LVRS and showed further deterioration. Overall survival rate at 5 years was 71.0% with the mean length of follow-up of 54.2 months. The survival difference was statistically significant between patients with preoperative FEV(1) >or=28.5% and those with FEV(1)<28.5% (P=0.0152). CONCLUSIONS: The improvement of total lung capacity and residual volume persisted long after the operation. Patients with alpha1-antitrypsin deficiency and those with bronchiolitis showed early deterioration of the lung function. Patients with higher preoperative FEV(1) had a survival benefit. The favorable long-term survival might justify LVRS for the treatment of selected patients with severe emphysema.     

电视胸腔镜肺减容术治疗27例重度肺气肿的疗效分析

目的探讨电视胸腔镜（VATS）下行肺减容术（LVRS）治疗重度肺气肿的临床疗效。方法回顾性分析27例重度肺气肿患者在电视胸腔镜下行LVRS的资料,其中双侧12例,单侧15例,切除每侧肺容积的20%～40%,比较手术前后的肺功能、血气分析等指标变化。结果 15例行VATS下单侧LVRS,4例同期行VATS下双侧LVRS,8例半年内分期行VATS下双侧LVRS,无死亡病例。术前与术后的各项指标比较,肺功能、血气分析及6min步行距离,差异有统计学意义。结论 VATS下LVRS治疗重度肺气肿可以取得良好疗效,双侧LVRS是更好的治疗手段。     

Technical issues and controversies in lung volume reduction surgery

The goal of lung volume reduction surgery (LVRS) is to safely palliate dyspnea in patients suffering from emphysema. Successful LVRS demands attention to the details of patient selection, preoperative preparation, intraoperative anesthetic and surgical technique and multidisciplinary postoperative care. Expertise in and effective communication between pulmonary medicine, thoracic surgery, thoracic anesthesia, pain management services, critical care medicine, respiratory therapy and rehabilitation medicine are vital components to any LVRS program. In experienced centers, bilateral approaches yield nearly twice the physiologic benefit to unilateral LVRS without adversely affecting operative morbidity or mortality. Current practice favors stapled resection over laser ablation to achieve volume reduction. Controversy persists regarding open versus video-assisted operations. The cost-effective need for and choice of materials to buttress staple-lines to reduce the incidence of postoperative air leak have yet to be defined. Ongoing multi-center, randomized, controlled trials should define the utility and durability of LVRS for appropriately selected patients and resolve some of the residual technical controversies. Therapeutic innovations may further reduce the invasiveness of lung volume reduction strategies and allow a more tailored approach to palliate patients with moderate to severe emphysema.     

Risks of mitral valve replacement and mitral valve replacement with coronary artery bypass

One hundred thirty consecutive patients who underwent mitral valve replacement (MVR) or MVR with coronary artery bypass grafting (CABG) using cold crystalloid cardioplegic solution were analyzed to determine operative mortality and risk factors. Twenty-eight patients had mitral stenosis (MS), 37 had mitral regurgitation (MR), 37 had mixed MS and MR, 23 had MR with coronary artery disease (CAD), and 5 had MS with CAD. Preoperative pulmonary artery pressure, pulmonary capillary wedge pressure, and cardiac index were not different among groups, but patients with MR and CAD had a significantly higher left ventricular end-diastolic pressure (LVEDP) and a significantly lower ejection fraction than other groups. Mortality was 7.1% for patients with MS, 5.4% for MR, 8.1% for mixed MS and MR, 0 for MS with CAD, and 21.7% for MR and CAD. Overall mortality was 9.2%. Eleven patients had emergency operations for cardiogenic shock with a mortality of 45%. Nineteen additional patients in New York Heart Association (NYHA) Functional Class IV had MVR or MVR plus CABG with a mortality of 26%. Sixteen patients required intraaortic balloon pump assistance, and 9 survived. Four patients with MR and CAD required the left ventricular assist device, and 3 survived. Excluding patients who had emergency operations, overall mortality was 5.8%. Excluding patients who had emergency operations and patients in NYHA Functional Class IV, overall mortality was 2%. Factors associated with death were cardiogenic shock, NYHA Class IV, LVEDP greater than 15 mm Hg (16% mortality), and age greater than 60 years (15% mortality).     

Mortality and morbidity among patients who undergo combined valve and coronary artery bypass surgery: Early and late results

Aim: To describe mortality and morbidity early and late after combined valve surgery and coronary artery bypass grafting (CABG) as compared with CABG alone. Patients and methods: All patients from western Sweden in whom CABG in combination with valve surgery or CABG alone was carried out in 1988–1991. Results: Among 2116 patients who underwent CABG, 35 (2%) had this combined with mitral valve surgery and 134 (6%) had this combined with aortic valve surgery, whereas the remaining 92% underwent CABG alone. Patients who underwent combined valve surgery and CABG were older, included more women and had a higher prevalence of previous congestive heart failure and renal dysfunction but on the other hand a less severe coronary artery disease. Among patients who underwent mitral valve surgery in combination with CABG the mortality over the subsequent 5 years was 45%. The corresponding figure for patients who underwent aortic valve surgery in combination with CABG was 24%. Both were higher than for CABG alone (14%; P<0.0001 and P=0.003, respectively). In a stepwise multiple regression model mitral valve surgery in combination with CABG was found to be an independent significant predictor for death but aortic valve surgery in combination with CABG was not. Among patients who underwent mitral valve surgery in combination with CABG and were discharged alive from hospital 77% were rehospitalized during the 2 years following the operation as compared with 48% among patients who underwent aortic valve surgery in combination with CABG and 43% among patients with CABG alone. Multiple regression identified mitral valve surgery in combination with CABG as a significant independent predictor for rehospitalization but not aortic valve plus CABG. Conclusion: Among patients who either underwent CABG in combination with mitral valve surgery or aortic valve surgery or CABG alone, mitral valve surgery in combination with CABG was independently associated with death and rehospitalization, but the combination of aortic valve surgery and CABG was not.     

Lung volume reduction surgery for the treatment of severe emphysema: a study in a single Canadian institution.

OBJECTIVE: To evaluate lung volume reduction surgery (LVRS) and its effectiveness in improving pulmonary function, exercise capacity and quality of life in a population of emphysema patients referred to and screened in a single centre. DESIGN: A prospective case series. SETTING: A Canadian tertiary care hospital. PATIENTS: Patients with severe emphysema, significant dyspnea and impaired exercise capacity interfering with quality of life. INTERVENTIONS: Bilateral LVRS was performed through a median sternotomy. MAIN OUTCOME MEASURES: Pulmonary function tests (preoperative forced expiratory volume in the first second [FEV1], residual volume [RV]), 6-minute walk (6 MW) distance, quality of life (Medical Outcomes Study 36-item short-form health survey) and degree of dyspnea (Medical Research Council of Great Britain dyspnea scale and the baseline and transitional dyspnea indices) were assessed before LVRS and at 6 and 12 months after. RESULTS: Fifty-seven patients were assessed for LVRS, of whom 10 were selected for surgery. Homogeneous distribution of disease was the most common reason for exclusion. Of the 10 patients operated upon, 1 died of acute cor pulmonale on the fourth postoperative day and 1 died of recurrent exacerbations of chronic obstructive pulmonary disease and chronic respiratory failure at 315 days postoperatively. In the surviving patients, the mean preoperative FEV1 increased from 0.70 L before surgery to 0.90 L at 1 year, with a mean relative increase of 33.4%. The mean RV decreased from 5.57 L to 4.10 L, with a mean relative decrease of 27.6%. The 6 MW distance increased from 302.7 m to 356.9 m at 1 year, with a mean relative increase of 21.6%. Quality of life and degree of dyspnea were improved significantly at 1 year after LVRS. Of the 5 patients on oxygen at home before surgery, 4 were able to reduce their requirements but not to discontinue oxygen. CONCLUSIONS: LVRS is an effective palliative treatment for dyspnea and poor exercise tolerance in highly selected patients. Although the duration of palliation is unknown, our results show that improvements in pulmonary function, exercise, quality of life and degree of dyspnea are preserved over the first year. Only a minority of the patients screened were eligible for surgery. The 2 deaths in our series emphasize the need for even further delineation of selection criteria.     

A Clinical Use of the Kyocera Gyro C1E3 Centrifugal Pump

In patients with reduced respiratory function, lung resection is associated with high risk because separate ventilation is generally needed for safe management. For patients with end-stage emphysema, intraoperative respiratory management is important and particularly difficult because neither incomplete oxygenation nor selective ventilation can be performed, so the operation may be interrupted. In this study, we assess the effectiveness of the percutaneous cardiopulmonary support (PCPS) system for lung volume reduction surgery in patients with severe hypercapnia (arterial carbon dioxide tension >50 mm Hg) and discuss the significance of PCPS for patients who are beyond the standard criteria for lung volume reduction surgery (LVRS). We studied 3 patients with severe hypercapnia due to emphysema who underwent volume reduction surgery. One patient was previously treated surgically for contralateral pneumothorax. All patients had a severe smoking history and were suspected to have fragile lungs. During the operation. PCPS provided sufficient support flow. Intraoperative management using PCPS was easy, and no severe complications were observed. One patient exhibited severe hemodynamic deterioration on postoperative Day 15. Other patients' PaCO2 improved postoperatively. One had a calcification of a femoral artery, but there was no trouble inserting a cannula. Bilateral or unilateral volume reduction surgery was performed under PCPS in patients with end-stage emphysema. We conclude that PCPS is an adjunct to LVRS, useful for intraoperative management of some patients with severe hypercapnea, and the LVRS indications can be extended.