# Expanding Lung Volume Reduction Surgery Indications: Outcomes in Patients Beyond Conventional National Emphysema Treatment Trial Criteria

## TL;DR

The study shows that lung volume reduction surgery can be safely performed in patients who don't meet strict criteria, with similar outcomes to standard patients.

## Contribution

The study expands the potential patient pool for LVRS by demonstrating comparable outcomes in patients beyond conventional criteria.

## Key findings

- Beyond-criteria patients had similar complication rates and functional improvements as standard-criteria patients.
- One 30-day LVRS-related death occurred in the standard group, but not in the beyond-criteria group.
- Careful multidisciplinary evaluation allows for safe LVRS in patients outside traditional guidelines.

## Abstract

Lung volume reduction surgery (LVRS) is guided by strict selection criteria from the National Emphysema Treatment Trial (NETT) to minimize risk and optimize outcomes. However, emerging evidence suggests that rigid cutoffs may exclude patients who could benefit. This study aimed to identify beyond-criteria patients undergoing LVRS and compare their outcomes with standard-criteria patients.

This single-centre retrospective analysis of a prospectively maintained database included all LVRS procedures from August 2019 until November 2024. Patients were classified as beyond-criteria if they met two or more of the following: age ≥ 75 years, body mass index (BMI) < 18.5 kg/m2, forced expiratory volume in 1 second (FEV1) < 20%pred, diffusing capacity for carbon monoxide (DLCO) < 20%pred, 6-minute walk distance (6MWD) < 140 m, homogeneous emphysema, systolic pulmonary arterial pressure (sPAP) > 35 mmHg, or prior thoracic interventions. Complications (Clavien-Dindo) and functional outcomes were assessed at 3, 6, and 12 months.

Twenty-one procedures were performed in 18 beyond-criteria patients versus 227 procedures in 191 standard-criteria patients. Among beyond-criteria patients: age ≥ 75 years (n = 3), BMI < 18.5 kg/m2 (n = 10), FEV1 < 20%pred (n = 5), DLCO < 20%pred (n = 1), 6MWD < 140 m (n = 1), homogeneous emphysema (n = 3), sPAP > 35 mmHg (n = 12), and prior thoracic intervention (n = 7). Complication rates were comparable (38% vs. 42%, P = .819 [95% CI, 0.93-1.10]), as were prolonged air leaks and hospital stay. One 30-day LVRS-related death (0.4%) occurred in the standard group. Functional and quality of life measures improved in both groups.

Beyond-criteria patients can be considered for LVRS when guided by careful multidisciplinary evaluation, with meaningful improvement in experienced centers.

Lung volume reduction surgery (LVRS) is a proven treatment for severe emphysema, a subtype of chronic obstructive pulmonary disease (COPD) marked by alveolar destruction resulting in air trapping and impaired gas exchange, leading to respiratory insufficiency and dyspnea.