Endoscopic Lung Volume Reduction with Endobronchial Valves in Patients with Severe Emphysema and Established Pulmonary Hypertension

Abstract

Background: One of the most common forms of pulmonary hypertension (PH) is that associated with chronic obstructive pulmonary disease (COPD). So far, patients with severe emphysema and established PH have been excluded from endoscopic lung volume reduction (ELVR) therapy due to the risk of right heart decompensation. Objective: The aim of this pilot study was to evaluate the feasibility and efficacy of ELVR using one-way endobronchial valves (EBV) in this specific group of patients. Methods: We prospectively included 6 patients with COPD, severe heterogeneous emphysema, and established PH who underwent right heart catheterization and clinical assessments before and 90 days after ELVR with unilateral EBV placement. Results: This study was not powered to measure any statistical differences in endpoints. Ninety days after ELVR, the symptoms, lung function, and hemodynamics improved in 5 out of 6 patients (1 patient normalized and 1 slightly worsened). The mean hemodynamics improved from baseline to 90 days after ELVR as follows: mean pulmonary artery pressure, -2.5 ± 3.5 mm Hg; pulmonary arterial wedge pressure, -4.3 ± 8.3 mm Hg; cardiac index, +0.3 ± 0.6 l/min/m², and 6-min walk distance, +59 ± 99 m. ELVR was performed without PH-related complications in all patients. Conclusion: To our knowledge, this is the first prospective, single-center pilot study to evaluate the feasibility and efficacy of ELVR in patients with established PH. ELVR was feasible and resulted in an improvement of clinical and hemodynamic parameters in 5 out of 6 patients. These results have to be further confirmed in larger-scale controlled studies.

Endoscopic Lung Volume Reduction: An Expert Panel Recommendation – Update 2019

“…In the case of severe PH, ELVR with coils, vapor, and sealants should be avoided. In selected cases with PH, EBV placement may be considered following multidisciplinary discussion [12]. Additionally, limited evidence has been published for successful valve treatment in emphysema patients with a FEV 1 < 20% pred.…”

Endobronchial Valves for Endoscopic Lung Volume Reduction: Best Practice Recommendations from Expert Panel on Endoscopic Lung Volume Reduction

“…Available clinical data have shown that EBV treatment benefits patients that are α 1 -antitrypsin deficient [13] , have homogeneous distribution of emphysema [4,9] , have upper or lower lobe predominant emphysema [14] , and have pulmonary hypertension [1,15] . Patients with unstable cardiovascular disease such as severe heart failure (left ventricular ejection fraction <35% despite optimal medical management), unstable cardiac arrhythmia, myocardial infarction, or stroke within the past 6 months should be excluded until stabilized or improved.…”

Endoscopic Lung Volume Reduction: An Expert Panel Recommendation - Update 2017

“…When an elevated right ventricular systolic pressure measured by echocardiography (>50 mm Hg) is identified, a right heart catheterization should be undertaken. In selected cases with pulmonary hypertension, endobronchial valve (EBV) placement may be considered following multidisciplinary discussion [9] . In our opinion, if they are excluded from valve placement due to pulmonary hypertension, they should not be considered suitable for any other current interventional or surgical procedures.…”