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Ann Thorac Surg 2007;83:241-251
© 2007 The Society of Thoracic Surgeons
-1 Antitrypsin Deficiency
a Division of Medicine, Section of Respiratory Therapy, The Cleveland Clinic Foundation, Cleveland, Ohio
b Department of Pulmonary, Allergy, and Critical Care Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio
d Department of Quantitative Health Sciences, The Cleveland Clinic Foundation, Cleveland, Ohio
c University of California, San Diego School of Medicine, San Diego, California
Accepted for publication July 28, 2006.
* Address correspondence to Dr Stoller, Department of Pulmonary, Allergy and Critical Care Medicine–A90, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195 (Email: stollej{at}ccf.org).
BACKGROUND: The role of lung volume reduction surgery (LVRS) for individuals with 
-1 antitrypsin (AAT) deficiency is unclear.
METHODS: To assess the role of LVRS in individuals with severe deficiency of AAT, outcomes within the National Emphysema Treatment Trial were analyzed.
RESULTS: Of 1218 randomized subjects, 16 (1.3%) had severe AAT deficiency (serum level < 80 mg/dL) and a consistent phenotype (when available). Characteristics of these 16 patients include 87.5% male; median serum AAT level, 55.5 mg/dL; age, 66 years; forced expiratory volume in 1 second (FEV1), 27% predicted; and 50% had upper-lobe-predominant emphysema. All 10 subjects randomized to LVRS underwent the procedure. Although the small number of subjects hampered statistical analysis, 2-year mortality was higher with surgery (20% versus 0%) than with medical treatment. Comparison of outcomes between the 10 AAT-deficient and the 554 AAT-replete subjects undergoing LVRS showed a greater increase in exercise capacity at 6 months in replete subjects and a trend toward lower and shorter duration FEV1 rise in deficient individuals.
CONCLUSIONS: This study extends to 49 cases the published experience of LVRS in severe AAT deficiency. Although the small number of subjects precludes firm conclusions, trends of lower magnitude and duration of FEV1 rise after surgery in AAT-deficient versus AAT-replete subjects and higher mortality in deficient individuals randomized to surgery versus medical treatment suggest caution in recommending LVRS in AAT deficiency.
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