Comparison of lung function and survival in high-risk vs. standard risk lung volume reduction surgery patients

Lung volume reduction surgery (LVRS) is an effective intervention for advanced emphysema. The National Emphysema Treatment Trial (NETT) identified a subgroup of patients considered high-risk (HR) for perioperative morbidity and mortality. This study evaluates the safety and outcomes of LVRS in this HR population.

A retrospective review was conducted of all patients who underwent LVRS between 2011 and 2024. HR patients were defined as having a preoperative forced expiratory volume in 1 second (FEV1) ≤20% with either diffusing capacity of the lung for carbon monoxide (DLCO) ≤20% or homogeneous emphysema on computed tomography (CT), confirmed by a board-certified radiologist per NETT methodology. All other patients were classified as standard risk (SR). Demographics, comorbidities, pulmonary function tests (PFTs), surgical approach, length of stay (LOS), and postoperative outcomes including lung transplantation (LTx) and survival were compared between groups. Kaplan-Meier analysis assessed long-term survival, with statistical significance set at P<0.05.

A total of 143 patients were identified, including 126 (88.1%) SR and 17 (11.9%) HR patients. The HR cohort had significantly worse baseline PFTs [FEV1: 17.4% vs. 32.8%, P<0.001; DLCO: 22.3% vs. 32.8%, P<0.001; residual volume (RV): 286.9% vs. 222.2%, P<0.001]. Both groups demonstrated significant postoperative improvements in PFTs within the first year, with HR patients showing a greater increase in DLCO% (P=0.01). LTx occurred in 2 SR patients (1.6%) and 1 HR patient (6%). There were no significant differences in LOS, 30-day postoperative pneumonia, transition to LTx, or overall survival.Conclusions: LVRS can be safely performed in NETT-defined HR patients, with comparable survival and transplant-free outcomes to SR patients. These findings support consideration of LVRS before LTx even in HR physiological subgroups.