- Lianne G Singer, MD, FRCPC
Lianne G Singer, MD, FRCPC
- Associate Professor of Medicine
- University of Toronto
Heart-lung transplantation is the procedure of choice for selected patients with concomitant end-stage heart failure and end-stage lung disease. Combined heart and lung transplantation is limited to patients in whom it offers the only surgical option for their end-stage cardiac and pulmonary disease. The procedure of choice for pulmonary parenchymal and vascular diseases in the absence of left heart dysfunction is single or double lung transplantation. (See 'Indications' below and "Lung transplantation: General guidelines for recipient selection".)
The first heart-lung transplantation was performed in 1981 in a patient with pulmonary arterial hypertension . The indications for the procedure were subsequently expanded to include patients with severe parenchymal lung disease and congenital heart disease complicated by Eisenmenger syndrome. (See "Management of Eisenmenger syndrome", section on 'Transplantation'.)
Indications, prognosis, and management of isolated heart transplantation and isolated lung transplantation are discussed separately. (See "Indications and contraindications for cardiac transplantation in adults" and "Prognosis after cardiac transplantation" and "Lung transplantation: An overview".)
Indications — Patients with concomitant refractory end-stage heart disease and chronic end-stage lung disease should undergo evaluation to determine if they are candidates for heart-lung transplantation. The most common indication for heart-lung transplantation is complex congenital heart disease with Eisenmenger syndrome (systemic-to-pulmonary communication, pulmonary arterial disease causing severe pulmonary hypertension, and cyanosis). Heart-lung transplant is also indicated in patients with concomitant end-stage pulmonary disease (eg, idiopathic pulmonary arterial hypertension [IPAH] or cystic fibrosis) and either right ventricular failure with objective evidence of right ventricular fibrosis or infarction or refractory left ventricular failure . The 2015 International Heart and Lung Transplantation (ISHLT) Registry summarized the distribution of diagnoses leading to adult heart-lung transplantation from January 1982 to June 2014 (slides available at http://www.ishlt.org/registries/slides.asp?slides=heartLungRegistry) . The three leading indications were congenital heart disease with Eisenmenger syndrome (35.4 percent), IPAH (27.6 percent), and cystic fibrosis (13.6 percent).
Where possible, isolated lung or heart transplantation is preferred to heart-lung transplantation because of several major disadvantages with the combined procedure. The need to procure a heart–lung block can lead to increased waiting time and increased mortality among patients awaiting combined heart-lung transplantation compared with those waiting for isolated heart or lung transplants. Other disadvantages include exposure of the recipient to risks of both graft coronary artery vasculopathy and chronic lung allograft dysfunction. In addition, heart-lung recipients may be disadvantaged by the obligate requirement for cardiopulmonary bypass during surgery and the physiological effects of a denervated heart. (See "Indications and contraindications for cardiac transplantation in adults".)
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- RECIPIENT SELECTION
- - Heart diseases
- - Lung diseases
- Timing of referral
- Donor evaluation
- Organ allocation
- Transplantation surgery
- POSTOPERATIVE MANAGEMENT
- Prevention of rejection
- Surveillance studies
- Early graft failure and primary graft dysfunction
- Acute cellular rejection
- Acute antibody-mediated rejection
- Chronic rejection
- - Phrenic nerve dysfunction
- - Gastroparesis
- - Chylothorax
- SUMMARY AND RECOMMENDATIONS