Surgical Fissure Completion Enables Endobronchial Valve Placement for Severe Emphysema with Collateral Ventilation

Endobronchial valves (EBV) improve outcomes in selected patients with severe emphysema but are ineffective in the presence of collateral ventilation. The COVE procedure (closure of collateral ventilation) combines video-assisted thoracoscopic (VATS) fissure completion with valve placement, enabling therapy in patients otherwise excluded.

This prospective, ethically approved study planned to recruit 20 patients but closed early due to the COVID-19 pandemic. Thirteen consented, one withdrawing and two proceeding to EBV. Ten consecutive patients underwent the COVE procedure. The primary endpoint was reduction in residual volume; secondary endpoints were changes in FEV₁, modified Medical Research Council dyspnoea score (mMRC), and 6-minute walk distance (6MWD). Survival was analysed using Kaplan-Meier methods and compared with outcomes predicted by the validated BODE Index, incorporating Body Mass Index, FEV₁, mMRC, and 6MWD.

The procedure was technically feasible, abolished collateral ventilation in all patients, and had no perioperative mortality. Complications were comparable to standard VATS or endobronchial interventions. Clinically meaningful improvements occurred in residual volume, quality-of-life, and exercise capacity (response rate 7/10, 70%). Based on baseline characteristics, the weighted BODE Index predicted 4-year-survival of 29.7%. Restricted mean survival time was 2.2 years. Observed survival exceeded this, at 80% 4-year-survival.

The COVE procedure is a novel thoracoscopic-bronchoscopic hybrid that enables valve therapy in patients with collateral ventilation, with encouraging safety, functional, and survival outcomes. Comparison with validated prognostic modelling suggests potential survival advantage, supporting multicentre evaluation to confirm efficacy and optimise patient selection.