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Heart-lung transplantation

Lianne G Singer, MD, FRCPC
Section Editor
Sharon A Hunt, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC


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 [1]. 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 [2]. The 2016 International Heart and Lung Transplantation (ISHLT) Registry summarized the distribution of diagnoses leading to adult heart-lung transplantation from January 2004 to June 2015 (slides available at http://www.ishlt.org/registries/slides.asp?slides=heartLungRegistry) [3]. The three leading indications were congenital heart disease (35.5 percent), IPAH (27.3 percent), and cardiomyopathy (11.2 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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Literature review current through: Nov 2017. | This topic last updated: Apr 28, 2017.
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  1. Reitz BA, Wallwork JL, Hunt SA, et al. Heart-lung transplantation: successful therapy for patients with pulmonary vascular disease. N Engl J Med 1982; 306:557.
  2. Weill D, Benden C, Corris PA, et al. A consensus document for the selection of lung transplant candidates: 2014--an update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2015; 34:1.
  3. Yusen RD, Edwards LB, Dipchand AI, et al. The Registry of the International Society for Heart and Lung Transplantation: Thirty-third Adult Lung and Heart-Lung Transplant Report-2016; Focus Theme: Primary Diagnostic Indications for Transplant. J Heart Lung Transplant 2016; 35:1170.
  4. Yusen RD, Edwards LB, Kucheryavaya AY, et al. The Registry of the International Society for Heart and Lung Transplantation: Thirty-second Official Adult Lung and Heart-Lung Transplantation Report--2015; Focus Theme: Early Graft Failure. J Heart Lung Transplant 2015; 34:1264.
  5. Mehra MR, Canter CE, Hannan MM, et al. The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update. J Heart Lung Transplant 2016; 35:1.
  6. Choong CK, Sweet SC, Guthrie TJ, et al. Repair of congenital heart lesions combined with lung transplantation for the treatment of severe pulmonary hypertension: a 13-year experience. J Thorac Cardiovasc Surg 2005; 129:661.
  7. Lamour JM, Hsu DT, Quaegebeur JM, et al. Heart transplantation to a physiologic single lung in patients with congenital heart disease. J Heart Lung Transplant 2004; 23:948.
  8. Afshar K, Weill D, Valentine V, Dhillon G. Comparison of double-lung and heart-lung transplantation for pulmonary hypertension: Analysis of the UNOS database. J Heart Lung Transplant 2009; 28:S310.
  9. de Perrot M, Granton JT, McRae K, et al. Outcome of patients with pulmonary arterial hypertension referred for lung transplantation: a 14-year single-center experience. J Thorac Cardiovasc Surg 2012; 143:910.
  10. Fadel E, Mercier O, Mussot S, et al. Long-term outcome of double-lung and heart-lung transplantation for pulmonary hypertension: a comparative retrospective study of 219 patients. Eur J Cardiothorac Surg 2010; 38:277.
  11. Olland A, Falcoz PE, Canuet M, Massard G. Should we perform bilateral-lung or heart–lung transplantation for patients with pulmonary hypertension? Interact Cardiovasc Thorac Surg 2013; 17:166.
  12. Schaffer JM, Singh SK, Joyce DL, et al. Transplantation for idiopathic pulmonary arterial hypertension: improvement in the lung allocation score era. Circulation 2013; 127:2503.
  13. Huddleston CB, Richey SR. Heart-lung transplantation. J Thorac Dis 2014; 6:1150.
  14. Starnes VA, Theodore J, Oyer PE, et al. Evaluation of heart-lung transplant recipients with prospective, serial transbronchial biopsies and pulmonary function studies. J Thorac Cardiovasc Surg 1989; 98:683.
  15. Guilinger RA, Paradis IL, Dauber JH, et al. The importance of bronchoscopy with transbronchial biopsy and bronchoalveolar lavage in the management of lung transplant recipients. Am J Respir Crit Care Med 1995; 152:2037.
  16. Boehler A, Vogt P, Zollinger A, et al. Prospective study of the value of transbronchial lung biopsy after lung transplantation. Eur Respir J 1996; 9:658.
  17. Kesten S, Chamberlain D, Maurer J. Yield of surveillance transbronchial biopsies performed beyond two years after lung transplantation. J Heart Lung Transplant 1996; 15:384.
  18. Girgis RE, Reichenspurner H, Robbins RC, et al. The utility of annual surveillance bronchoscopy in heart-lung transplant recipients. Transplantation 1995; 60:1458.
  19. Pinderski LJ, Kirklin JK, McGiffin D, et al. Multi-organ transplantation: is there a protective effect against acute and chronic rejection? J Heart Lung Transplant 2005; 24:1828.
  20. Keenan RJ, Bruzzone P, Paradis IL, et al. Similarity of pulmonary rejection patterns among heart-lung and double-lung transplant recipients. Transplantation 1991; 51:176.
  21. Baldwin JC, Oyer PE, Stinson EB, et al. Comparison of cardiac rejection in heart and heart-lung transplantation. J Heart Transplant 1987; 6:352.
  22. Griffith BP, Hardesty RL, Trento A, Bahnson HT. Asynchronous rejection of heart and lungs following cardiopulmonary transplantation. Ann Thorac Surg 1985; 40:488.
  23. Glanville AR, Imoto E, Baldwin JC, et al. The role of right ventricular endomyocardial biopsy in the long-term management of heart-lung transplant recipients. J Heart Transplant 1987; 6:357.
  24. Vricella LA, Karamichalis JM, Ahmad S, et al. Lung and heart-lung transplantation in patients with end-stage cystic fibrosis: the Stanford experience. Ann Thorac Surg 2002; 74:13.
  25. Ganesh JS, Rogers CA, Bonser RS, et al. Outcome of heart-lung and bilateral sequential lung transplantation for cystic fibrosis: a UK national study. Eur Respir J 2005; 25:964.
  26. Moffatt-Bruce SD, Karamichalis J, Robbins RC, et al. Are heart-lung transplant recipients protected from developing bronchiolitis obliterans syndrome? Ann Thorac Surg 2006; 81:286.
  27. Levine DJ, Glanville AR, Aboyoun C, et al. Antibody-mediated rejection of the lung: A consensus report of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2016; 35:397.
  28. Reed EF, Demetris AJ, Hammond E, et al. Acute antibody-mediated rejection of cardiac transplants. J Heart Lung Transplant 2006; 25:153.
  29. Miller GG, Destarac L, Zeevi A, et al. Acute humoral rejection of human lung allografts and elevation of C4d in bronchoalveolar lavage fluid. Am J Transplant 2004; 4:1323.
  30. Girnita AL, McCurry KR, Iacono AT, et al. HLA-specific antibodies are associated with high-grade and persistent-recurrent lung allograft acute rejection. J Heart Lung Transplant 2004; 23:1135.
  31. Ionescu DN, Girnita AL, Zeevi A, et al. C4d deposition in lung allografts is associated with circulating anti-HLA alloantibody. Transpl Immunol 2005; 15:63.
  32. Magro CM, Deng A, Pope-Harman A, et al. Humorally mediated posttransplantation septal capillary injury syndrome as a common form of pulmonary allograft rejection: a hypothesis. Transplantation 2002; 74:1273.
  33. Magro CM, Pope Harman A, Klinger D, et al. Use of C4d as a diagnostic adjunct in lung allograft biopsies. Am J Transplant 2003; 3:1143.
  34. Wallace WD, Reed EF, Ross D, et al. C4d staining of pulmonary allograft biopsies: an immunoperoxidase study. J Heart Lung Transplant 2005; 24:1565.
  35. Verleden GM, Raghu G, Meyer KC, et al. A new classification system for chronic lung allograft dysfunction. J Heart Lung Transplant 2014; 33:127.
  36. Estenne M, Maurer JR, Boehler A, et al. Bronchiolitis obliterans syndrome 2001: an update of the diagnostic criteria. J Heart Lung Transplant 2002; 21:297.
  37. Sato M, Waddell TK, Wagnetz U, et al. Restrictive allograft syndrome (RAS): a novel form of chronic lung allograft dysfunction. J Heart Lung Transplant 2011; 30:735.
  38. Sheridan PH Jr, Cheriyan A, Doud J, et al. Incidence of phrenic neuropathy after isolated lung transplantation. The Loyola University Lung Transplant Group. J Heart Lung Transplant 1995; 14:684.
  39. Ferdinande P, Bruyninckx F, Van Raemdonck D, et al. Phrenic nerve dysfunction after heart-lung and lung transplantation. J Heart Lung Transplant 2004; 23:105.
  40. Berkowitz N, Schulman LL, McGregor C, Markowitz D. Gastroparesis after lung transplantation. Potential role in postoperative respiratory complications. Chest 1995; 108:1602.
  41. Sodhi SS, Guo JP, Maurer AH, et al. Gastroparesis after combined heart and lung transplantation. J Clin Gastroenterol 2002; 34:34.
  42. Raviv Y, D'Ovidio F, Pierre A, et al. Prevalence of gastroparesis before and after lung transplantation and its association with lung allograft outcomes. Clin Transplant 2012; 26:133.
  43. Yiannopoulos A, Shafazand S, Ziedalski T, et al. Gastric pacing for severe gastroparesis in a heart-lung transplant recipient. J Heart Lung Transplant 2004; 23:371.
  44. Weinkauf JG, Yiannopoulos A, Faul JL. Transcutaneous electrical nerve stimulation for severe gastroparesis after lung transplantation. J Heart Lung Transplant 2005; 24:1444.
  45. Ziedalski TM, Raffin TA, Sze DY, et al. Chylothorax after heart/lung transplantation. J Heart Lung Transplant 2004; 23:627.
  46. Lund LH, Edwards LB, Dipchand AI, et al. The Registry of the International Society for Heart and Lung Transplantation: Thirty-third Adult Heart Transplantation Report-2016; Focus Theme: Primary Diagnostic Indications for Transplant. J Heart Lung Transplant 2016; 35:1158.
  47. Harringer W, Wiebe K, Strüber M, et al. Lung transplantation--10-year experience. Eur J Cardiothorac Surg 1999; 16:546.
  48. Burton CM, Milman N, Carlsen J, et al. The Copenhagen National Lung Transplant Group: survival after single lung, double lung, and heart-lung transplantation. J Heart Lung Transplant 2005; 24:1834.