Is pulmonary hypertension still a contraindication for lung volume reduction?—a narrative review of contemporary evidence

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Background and Objective: Severe emphysema in chronic obstructive pulmonary disease causes lung hyperinflation, increased intrathoracic pressure and loss of pulmonary vasculature, which together contribute to pulmonary hypertension (PH) and right heart dysfunction. Historically, PH was considered an absolute contraindication to lung volume reduction surgery (LVRS) because clinicians feared that removing lung tissue and pulmonary vessels would raise pulmonary artery pressures and provoke right-heart failure. The objective of this narrative review is to synthesize recent evidence on the safety, feasibility and haemodynamic impact of LVRS and bronchoscopic lung volume reduction (BLVR) in patients with emphysema-associated PH and to propose practical recommendations for future research and clinical practice. Methods: We searched PubMed, MEDLINE and Web of Science from January 1990 to January 2026 using combinations of related to lung volume reduction (LVR) and PH. Reference lists of key articles were manually screened. Both surgical and bronchoscopic interventions were considered, and study designs ranging from randomized trials to observational cohorts and case series were eligible due to limited randomized data. Hemodynamic and clinical endpoints were extracted and narratively synthesized. Key Content and Findings: Lung hyperinflation compresses the heart and pulmonary vessels, raising pulmonary artery pressures and reducing venous return and cardiac output. LVR decreases intrathoracic pressure and improves ventilation-perfusion matching; endobronchial valves improve lung function, exercise capacity and survival. A total of 21 studies were included, comprising one randomised control trial [the National Emphysema Treatment Trial (NETT) cardiovascular substudy], 15 observational cohort studies, and 5 case series. Overall, the literature consistently indicates that the benefits of LVR on respiratory mechanics may offset the theoretical risk of losing pulmonary vasculature, provided PH is mild to moderate and patients are carefully assessed. Conclusions: Current evidence challenges the dogma that PH is an absolute contraindication to LVR. In selected emphysema patients with heterogeneous disease and mild-to-moderate PH, LVRS and BLVR can be performed safely and may reduce pulmonary artery pressures and improve right-ventricular function. Right heart catheterisation should be strongly considered for haemodynamic phenotyping before intervention and multidisciplinary selection protocols are recommended. Severe PH or decompensated right-heart failure remains a relative contraindication, and bronchoscopic procedures should be reserved for carefully selected cases.

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