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Abia-Trujillo D, Johnson MM, Patel NM, Hazelett B, Edell ES, Kern RM, Midthun D, Reisenauer J, Nelson D, Mullon JJ, Sakata KK, Swanson K, Fernandez-Bussy S. Bronchoscopic Lung Volume Reduction: A New Hope for Patients With Severe Emphysema and Air Trapping. Mayo Clin Proc 2021; 96:464-472. [PMID: 32829903 DOI: 10.1016/j.mayocp.2020.03.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/25/2020] [Accepted: 03/31/2020] [Indexed: 10/23/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is common and has significant morbidity and mortality as the fourth leading cause of death in the United States. In many patients, particularly those with emphysema, COPD is characterized by markedly increased residual volume contributing to exertional dyspnea. Current therapies have limited efficacy. Surgical resection of diseased areas of the lung to reduce residual volume was effective in identified subgroups but also had significant mortality in and suboptimal cost effectiveness. Lung-volume reduction, using bronchoscopic techniques, has shown substantial benefits in a broader patient population with less morbidity and mortality. This review is meant to spread the awareness about bronchoscopic lung-volume reduction and to promote its consideration and early referral for patients with advanced COPD and emphysema frequently encountered by both primary care physicians and specialists. A search was conducted on PubMed (MEDLINE), EMbase, and Cochrane library for original studies, using the following keywords: "lung-volume reduction." "endobronchial valves," "intrabronchial valves," "bronchoscopic lung-volume reduction," and "endoscopic lung-volume reduction." We included reports from systematic reviews, narrative reviews, clinical trials, and observational studies. Two reviewers evaluated potential references. A total of 27 references were included in our review. Included studies report experience in the diagnosis and bronchoscopic treatment for emphysema; case reports and non-English or non-Spanish studies were excluded.
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Affiliation(s)
- David Abia-Trujillo
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Margaret M Johnson
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Neal M Patel
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Britney Hazelett
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Eric S Edell
- Division of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | - Ryan M Kern
- Division of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | - David Midthun
- Division of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | | | - Darlene Nelson
- Division of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | - John J Mullon
- Division of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | | | - Karen Swanson
- Division of Pulmonary Medicine, Mayo Clinic, Phoenix, AZ
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Tenda ED, Ridge CA, Shen M, Yang GZ, Shah PL. Role of Quantitative Computed Tomographic Scan Analysis in Lung Volume Reduction for Emphysema. Respiration 2019; 98:86-94. [PMID: 31067563 DOI: 10.1159/000498949] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 02/15/2019] [Indexed: 11/19/2022] Open
Abstract
Recent advances in bronchoscopic lung volume reduction (BLVR) offer new therapeutic alternatives for patients with emphysema and hyperinflation. Endobronchial valves and coils are 2 potential BLVR techniques which have been shown to improve pulmonary function and the quality of life in patients with emphysema. Current patient selection for LVR procedures relies on 3 main inclusion criteria: low attenuation area (in %), also known as emphysema score, heterogeneity score, and fissure integrity score. Volumetric analysis in combination with densitometric analysis of the affected lung lobe or segment with quantitative CT to determine emphysema severity play an important role in treatment planning and post-operative assessment. Due to the variations in lung anatomy, manual corrections are often required to ensure successful and accurate lobe segmentation for pathological and post-treatment CT scan analysis. The advanced development and utilisation of quantitative CT do not simply represent regional changes in pulmonary function but aids in analysis for better patient selection with severe emphysema who are most likely to benefit from BLVR.
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Affiliation(s)
- Eric Daniel Tenda
- National Heart and Lung Institute, Imperial College, London, United Kingdom.,Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom.,The Hamlyn Centre for Robotic Surgery, Imperial College London, London, United Kingdom.,Division of Pulmonology, Department of Internal Medicine, National General Hospital of Dr. Cipto Mangunkusumo, and Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Carole A Ridge
- Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Mali Shen
- The Hamlyn Centre for Robotic Surgery, Imperial College London, London, United Kingdom
| | - Guang-Zhong Yang
- The Hamlyn Centre for Robotic Surgery, Imperial College London, London, United Kingdom
| | - Pallav L Shah
- National Heart and Lung Institute, Imperial College, London, United Kingdom, .,Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom,
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Poggi C, Mantovani S, Pecoraro Y, Carillo C, Bassi M, D'Andrilli A, Anile M, Rendina EA, Venuta F, Diso D. Bronchoscopic treatment of emphysema: an update. J Thorac Dis 2018; 10:6274-6284. [PMID: 30622803 DOI: 10.21037/jtd.2018.10.43] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is the major causes of disability and mortality. The efficacy of maximal medical treatment, although effective at the early stages of the disease, becomes limited when extensive alveolar destruction is the main cause of respiratory failure. At this stage of the disease more aggressive options, when feasible, should be considered. Lung transplantation and lung volume reduction surgery (LVRS) are currently available for a selected group of patients. Endoscopic alternatives to LVRS have progressively gained acceptance and are currently employed in patients with COPD. They promote lung deflation searching the same outcome as LVRS in terms of respiratory mechanics, ameliorating the distressing symptom of chronic dyspnea by decreasing the physiological dead space.
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Affiliation(s)
- Camilla Poggi
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Sara Mantovani
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Ylenia Pecoraro
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Carolina Carillo
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Massimiliano Bassi
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Antonio D'Andrilli
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Marco Anile
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Erino A Rendina
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Federico Venuta
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Daniele Diso
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
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Welling JBA, Slebos DJ. Lung volume reduction with endobronchial coils for patients with emphysema. J Thorac Dis 2018; 10:S2797-S2805. [PMID: 30210833 DOI: 10.21037/jtd.2017.12.95] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The lung volume reduction coil treatment is a minimally invasive bronchoscopic treatment option for emphysema patients who suffer from severe hyperinflation. The treatment is aimed at a large group of patients where lung volume reduction surgery and bronchoscopic lung volume reduction using endobronchial valves are no option, or alternatively, can be offered as a bridge to lung transplantation. The nitinol coil exhibits a shape memory effect and is biologically inert. The lung volume reduction coil procedure is performed in two separate treatment sessions, targeting one lobe per session, with the contralateral lobe being treated 4 to 8 weeks after the first session. In one treatment session, around 10 to 14 coils, thereby treating an entire lobe, are being placed. Selecting optimally treated, symptomatic chronic obstructive pulmonary disease (COPD) patients with emphysema and severe hyperinflation, while avoiding significant airway disease such as asthma, chronic bronchitis and bronchiectasis, is key to achieve treatment success. Three randomized clinical trials investigating lung volume reduction coil treatment have been published until now, reporting the results of 452 treated patients up to 12 months after coil treatment. Lung volume reduction coil treatment results in significant improvement of pulmonary function outcomes and quality of life in patients with severe hyperinflation. The most common complications of lung volume reduction coil treatment are: COPD exacerbations, pneumonia, Coil Associated Opacity and an increased risk of pneumothorax. The purpose of this article is to describe the coil technique and review the available literature regarding effect, safety and future perspectives of lung volume reduction with coils for emphysema patients.
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Affiliation(s)
- Jorrit B A Welling
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Vanfleteren MJ, Koopman M, Spruit MA, Pennings HJ, Smeenk F, Pieters W, van den Bergh JJ, Michels AJ, Wouters EF, Groenen MT, Franssen FM, Vanfleteren LE. Effectiveness of Pulmonary Rehabilitation in Patients With Chronic Obstructive Pulmonary Disease With Different Degrees of Static Lung Hyperinflation. Arch Phys Med Rehabil 2018; 99:2279-2286.e3. [PMID: 29906421 DOI: 10.1016/j.apmr.2018.05.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 03/31/2018] [Accepted: 05/07/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the effect of pulmonary rehabilitation (PR) on exercise performance and quality of life in patients with chronic obstructive pulmonary disease (COPD) with different degrees of static lung hyperinflation (LH). DESIGN Retrospective cohort study. SETTING PR network. PARTICIPANTS A cohort of 1981 patients with COPD (55% men; age: 66.8±9.3y; forced expiratory volume in the first second%: 50.7±19.5; residual volume [RV]%: 163.0±49.7). INTERVENTION An interdisciplinary PR program for patients with COPD consisting of 40 sessions. MAIN OUTCOME MEASURES Participants were stratified into 5 quintiles according to baseline RV and were evaluated on the basis of pre- and post-PR 6-minute walk distance (6MWD), constant work rate test (CWRT), and Saint George's Respiratory Questionnaire (SGRQ), among other clinical parameters. RESULTS With increasing RV quintile, patients were younger, more frequently women, had lower forced expiratory volume in the first second%, lower body mass index and fat-free mass index, shorter 6MWD, shorter CWRT, and worse SGRQ scores (P<.01). All RV strata improved after PR in all 3 outcomes (P<.001). Nevertheless, higher, compared to lower RV categories, had lower ΔCWRT (P<.01) but similar Δ6MWD (P=.948) and ΔSGRQ (P=.086) after PR. CONCLUSIONS LH in COPD is related to younger age, female sex, lower body weight, worse exercise capacity and health status, but did not prevent patients from benefitting from PR. LH, however, influences walking and cycling response after PR differently.
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Affiliation(s)
- Michiel J Vanfleteren
- Department of Research and Education, Center of Expertise for Chronic Organ Failure (CIRO), Horn, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands.
| | - Maud Koopman
- Department of Research and Education, Center of Expertise for Chronic Organ Failure (CIRO), Horn, the Netherlands
| | - Martijn A Spruit
- Department of Research and Education, Center of Expertise for Chronic Organ Failure (CIRO), Horn, the Netherlands
| | - Herman-Jan Pennings
- Department of Respiratory Medicine, St. Laurentius Hospital, Roermond, the Netherlands
| | - Frank Smeenk
- Department of Respiratory Medicine, Catharina Hospital, Eindhoven, the Netherlands
| | - Willem Pieters
- Department of Respiratory Medicine, Elkerliek Hospital, Helmond, the Netherlands
| | - Jan J van den Bergh
- Department of Respiratory Medicine, St. Jans Gasthuis, Weert, the Netherlands
| | - Arent-Jan Michels
- Department of Respiratory Medicine, St Anna Hospital, Geldrop, the Netherlands
| | - Emiel F Wouters
- Department of Research and Education, Center of Expertise for Chronic Organ Failure (CIRO), Horn, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Miriam T Groenen
- Department of Research and Education, Center of Expertise for Chronic Organ Failure (CIRO), Horn, the Netherlands
| | - Frits M Franssen
- Department of Research and Education, Center of Expertise for Chronic Organ Failure (CIRO), Horn, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Lowie E Vanfleteren
- Department of Research and Education, Center of Expertise for Chronic Organ Failure (CIRO), Horn, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands; COPD Center, Sahlgrenska University Hospital, Göteborg, Sweden
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Hartman JE, Klooster K, Groen H, Ten Hacken NHT, Slebos DJ. Cost-effectiveness of endobronchial valve treatment in patients with severe emphysema compared to standard medical care. Respirology 2018; 23:835-841. [PMID: 29575395 DOI: 10.1111/resp.13295] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 02/23/2018] [Accepted: 02/26/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Bronchoscopic lung volume reduction using endobronchial valves (EBV) is an effective new treatment option for severe emphysema patients without interlobar collateral ventilation. The objective of this study was to perform an economic evaluation including the costs and cost-effectiveness of EBV treatment compared with standard medical care (SoC) from the hospital perspective in the short term and long term. METHODS For the short-term evaluation, incremental cost-effectiveness ratios (ICER) were calculated based on the 6-month end point data from the STELVIO randomized trial. For the long-term evaluation, a Markov simulation model was constructed based on STELVIO and literature. The clinical outcome data were quality-adjusted life-years (QALY) based on the EuroQol5-Dimensions (EQ5D) questionnaire, the 6-min walking distance (6MWD) and the St George's Respiratory Questionnaire (SGRQ). RESULTS The mean difference between the EBV group and controls was €16 721/patient. In the short-term (6 months), costs per additional QALY was €205 129, the ICER for 6MWD was €160 and for SGRQ was €1241. In the long term, the resulting cost-effectiveness ratios indicate additional costs of €39 000 per QALY gained with a 5-year time horizon and €21 500 per QALY gained at 10 years. In comparison, historical costs per additional QALY 1 year after the coil treatment are €738 400, 5 years after lung volume reduction surgery are €48 415 and 15 years after double-lung transplantation are €29 410. CONCLUSION The positive clinical effects of EBV treatment are associated with increased costs compared with SoC. Our results suggest that the EBV treatment has a favourable cost-effectiveness profile, also when compared with other treatment modalities for this patient group.
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Affiliation(s)
- Jorine E Hartman
- Department of Pulmonary Diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Karin Klooster
- Department of Pulmonary Diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Henk Groen
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Nick H T Ten Hacken
- Department of Pulmonary Diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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Hetzel J, Boeckeler M, Horger M, Ehab A, Kloth C, Wagner R, Freitag L, Slebos DJ, Lewis RA, Haentschel M. A new functional method to choose the target lobe for lung volume reduction in emphysema - comparison with the conventional densitometric method. Int J Chron Obstruct Pulmon Dis 2017; 12:2621-2628. [PMID: 28919730 PMCID: PMC5586979 DOI: 10.2147/copd.s139304] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Lung volume reduction (LVR) improves breathing mechanics by reducing hyperinflation. Lobar selection usually focuses on choosing the most destroyed emphysematous lobes as seen on an inspiratory CT scan. However, it has never been shown to what extent these densitometric CT parameters predict the least deflation of an individual lobe during expiration. The addition of expiratory CT analysis allows measurement of the extent of lobar air trapping and could therefore provide additional functional information for choice of potential treatment targets. Objectives To determine lobar vital capacity/lobar total capacity (LVC/LTC) as a functional parameter for lobar air trapping using on an inspiratory and expiratory CT scan. To compare lobar selection by LVC/LTC with the established morphological CT density parameters. Methods 36 patients referred for endoscopic LVR were studied. LVC/LTC, defined as delta volume over maximum volume of a lobe, was calculated using inspiratory and expiratory CT scans. The CT morphological parameters of mean lung density (MLD), low attenuation volume (LAV), and 15th percentile of Hounsfield units (15%P) were determined on an inspiratory CT scan for each lobe. We compared and correlated LVC/LTC with MLD, LAV, and 15%P. Results There was a weak correlation between the functional parameter LVC/LTC and all inspiratory densitometric parameters. Target lobe selection using lowest lobar deflation (lowest LVC/LTC) correlated with target lobe selection based on lowest MLD in 18 patients (50.0%), with the highest LAV in 13 patients (36.1%), and with the lowest 15%P in 12 patients (33.3%). Conclusion CT-based measurement of deflation (LVC/LTC) as a functional parameter correlates weakly with all densitometric CT parameters on a lobar level. Therefore, morphological criteria based on inspiratory CT densitometry partially reflect the deflation of particular lung lobes, and may be of limited value as a sole predictor for target lobe selection in LVR.
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Affiliation(s)
- Juergen Hetzel
- Division of Haematology, Oncology, Rheumatology, Immunology and Pulmonology, Department of Internal Medicine
| | - Michael Boeckeler
- Division of Haematology, Oncology, Rheumatology, Immunology and Pulmonology, Department of Internal Medicine
| | - Marius Horger
- Department of Diagnostic and Interventional Radiology
| | - Ahmed Ehab
- Division of Haematology, Oncology, Rheumatology, Immunology and Pulmonology, Department of Internal Medicine
| | | | - Robert Wagner
- Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry, Department of Internal Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Lutz Freitag
- Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Richard Alexander Lewis
- National Pollen and Aerobiology Research Unit, Institute of Science and the Environment, University of Worcester, Worcester, UK
| | - Maik Haentschel
- Division of Haematology, Oncology, Rheumatology, Immunology and Pulmonology, Department of Internal Medicine
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The importance of patient selection for lung volume reduction. CURRENT PULMONOLOGY REPORTS 2016. [DOI: 10.1007/s13665-016-0153-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW Several lung volume reduction (LVR) techniques have been increasingly evaluated in patients with advanced pulmonary emphysema, especially in the last decade. Radiologist plays a pivotal role in the characterization of parenchymal damage and, thus, assessment of eligibility criteria. This review aims to discuss the most common LVR techniques, namely LVR surgery, endobronchial valves, and coils LVR, with emphasis on the role of computed tomography (CT). RECENT FINDINGS Several trials have recently highlighted the importance of regional quantification of emphysema by computerized CT-based segmentation of hyperlucent parenchyma, which is strongly recommended for candidates to any LVR treatment. In particular, emphysema distribution pattern and fissures integrity are evaluated to tailor the choice of the most appropriate LVR technique. Furthermore, a number of CT measures have been tested for the personalization of treatment, according to imaging detected heterogeneity of parenchymal disease. SUMMARY CT characterization of heterogeneous parenchymal abnormalities provides criteria for selection of the preferable treatment in each patient and improves outcome of LVR as reflected by better quality of life, higher exercise tolerance, and lower mortality.
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