Lung volume reduction surgery beyond the NETT selection criteria

Lung volume reduction surgery (LVRS) for symptomatic patients with advanced emphysema was proven to be successful in a large randomized multi-center trial (NETT) and in several smaller randomized single center trials. This evidence primarily concerns patients with heterogeneous, upper-lobe predominant emphysema and low exercise tolerance within certain selection criteria regarding lung function values. As the most important effect of LVRS is generated by reducing the hyperinflation, even patients with homogeneous emphysema morphology profit from the procedure. Simultaneously, by removing distended and functionless areas in heterogeneous emphysema, also patients with seriously impaired diffusion capacity, moderate pulmonary arterial hypertension, a history of previous LVRS and alpha-1-antitrypsin-deficiency (AATD) can be considered as candidates for (re-)-LVRS. This article summarizes indications for LVRS in these various subtypes of emphysema patients.