Lung Volume Reduction Followed by Lung Transplantation in Emphysema-A Multicenter Matched Analysis

[Indications for Lung Transplantation - Updates Since the Last ISHLT Recommendations]

Lung transplantation has evolved continuously since its first successful procedures in the 1960 s. The current guidelines from the International Society for Heart and Lung Transplantation (ISHLT) emphasise increasingly individualised patient assessment, which, in addition to the underlying lung disease, considers factors such as comorbidities, frailty, age, and social aspects. The expanded indications for lung transplantation are reflected in the refined risk assessment, which particularly includes patients with advanced chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), and pulmonary arterial hypertension (PAH). Furthermore, the criteria for patients with a history of cancer and those with infections such as HIV or multidrug-resistant organisms have been made more flexible, leading to a more inclusive transplantation policy. A key focus is on early transplant counselling, allowing patients the opportunity for transplantation before they develop acute exacerbations. These updated guidelines aim to maximise both the survival rates and the quality of life of transplant patients, through differentiated and risk-adjusted decision-making.

[Lung Volume Reduction Surgery - an Alternative or a Bridge to Transplantation]

Lung volume reduction surgery (LVRS) and lung transplantation (LuTX) are established therapeutic options for patients with advanced pulmonary emphysema. This review analyses both procedures with respect to indications, surgical techniques, outcomes, and complications. Special attention is given to the controversial sequential application as a bridge to transplantation. Evidence shows that both procedures can significantly improve lung function, quality of life, and survival when patients are carefully selected. Despite some overlap in indication criteria, most patients qualify for only one of the procedures as based on their specific clinical constellation. Recent research has challenged traditional contraindications such as pulmonary hypertension or homogeneous emphysema, and consequently, the indication spectrum for LVRS has been expanded. Contrary to earlier assumptions, current multicentre studies demonstrate that prior LVRS has no negative impact on subsequent transplantation outcomes, provided minimally invasive surgical techniques and modern perioperative management are employed. LVRS can delay the need for transplantation, which is a significant advantage given the shortage of donor organs. The key to success lies in interdisciplinary evaluation and personalized treatment planning. Both procedures should be understood as complementary rather than competing options. Future research should focus on predictive biomarkers, optimal timing, and combined patient-centred endpoints.

The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2022 Part I: Lung Transplantation

These highlights focus on the research in lung transplantation (LTX) that was published in 2022 and includes the assessment and optimization of candidates for LTX, donor optimization, the use of organs from donation after circulatory death, and outcomes when using marginal or novel donors; recipient factors affecting LTX, including age, disease, the use of extracorporeal life support; and special situations, such as coronavirus disease2019, pediatric LTX, and retransplantation. The remainder of the article focuses on the perioperative management of LTX, including the perioperative risk factors for acute renal failure (acute kidney injury); the incidence and management of phrenic nerve injury, delirium, and pain; and the postoperative management of hyperammonemia, early postoperative infections, and the use of donor-derived cell-free DNA to detect rejection.

Surgical and bronchoscopic pulmonary function-improving procedures in lung emphysema

COPD is a highly prevalent, chronic and irreversible obstructive airway disease without curative treatment. Standard therapeutic strategies, both non-pharmacological and pharmacological, have only limited effects on lung function parameters of patients with severe disease. Despite optimal pharmacological treatment, many patients with severe COPD still have a high burden of dyspnoea and a poor quality of life. If these patients have severe lung emphysema, with hyperinflation as the driver of symptoms and exercise intolerance, lung volume reduction may be an effective treatment with a significant impact on lung function, exercise capacity and quality of life. Currently, different lung volume reduction approaches, both surgical and bronchoscopic, have shown encouraging results and have been implemented in COPD treatment recommendations. Nevertheless, choosing the optimal lung volume reduction strategy for an individual patient remains challenging. Moreover, there is still room for improving durability of effect and safety in all available procedures. Ongoing and innovative research is essential to push this field forwards. This review provides an overview of results and limitations of the current lung volume reduction options for patients with severe lung emphysema and hyperinflation.

Surgical and Interventional Approaches in COPD

Many patients suffer from complaints of dyspnea, cough, and sputum production, clinical symptoms that hallmark the structural abnormalities that are present in patients with COPD. Although pharmacologic and non-pharmacologic medical therapies help reduce these symptoms, many of these symptoms, especially dyspnea, remain unchecked and contribute to the burden of disease in patients with COPD. Over the last 3 decades, several surgical and interventional treatments delivered via a bronchoscopic approach have been developed to complement medical therapies and show promise to improve patient outcomes. Surgical and interventional treatments target structural abnormalities of the airway and lung parenchyma that can be identified with a combination of imaging and physiological testing, factors that are key to select patients most likely to benefit from these treatments. This paper reviews surgical and bronchoscopic interventional treatment options for patients with emphysema and airways disorders.