Abstract
OBJECTIVES: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: Beyond-criteria patients can be considered for LVRS when guided by careful multidisciplinary evaluation, with meaningful improvement in experienced centers.