Chapter 95

The decision to perform a single-, double-, or heart-lung transplant depends on numerous factors, including recipient characteristics (e.g., disease, age, and comorbidities), institutional bias, organ availability, and the urgency of the transplant. Single-lung transplantation is a good option for patients with idiopathic pulmonary fibrosis.1 Selected patients with emphysema, specifically those of shorter stature and older age, also can expect good results with single-lung transplantation. Unilateral transplantation is also acceptable for patients with primary pulmonary hypertension (PPH).2 However, because these cases are challenging and management can be difficult during the first few postoperative days,3 some programs prefer the double- or even combined heart-lung transplantation for patients with PPH. Double-lung transplant is mandatory for patients with cystic fibrosis (CF) and bronchiectasis because in both cases the septic native lungs must be excised. When the native disease is accompanied by a preexisting mycetoma4 or other chronic fungal or mycobacterial infection, double-lung transplantation is also a better option because it minimizes the posttransplant risk of recurrent infection. The heart-lung transplant is reserved for the rare patient with combined end-stage cardiac and pulmonary disease. Most patients requiring heart-lung transplant have Eisenmenger's syndrome with PPH and significant left ventricular dysfunction, perhaps owing to an uncorrected congenital defect. The annual rate of heart-lung transplantation has declined by more than 50% since 1995 not only because single- or double-lung transplant alone is appropriate in the majority of patients but also because no clear survival advantage has been demonstrated in this patient group.5

We prefer the double-lung transplant at our institution irrespective of disease category. Double-lung transplantation has been documented to produce a superior result in patients with obstructive lung disease,6 and we find that survival is superior and that early postoperative management is far less complicated with the bilateral approach.

The International Society of Heart and Lung Transplantation registry summarizes the indications for transplantation on a yearly basis (see Fig. 94-3). We have experienced a similar distribution of cases in the more than 800 lung transplants performed at Barnes-Jewish Hospital since inception of its lung transplant program (Fig. 95-1). Most of our patients present with chronic obstructive pulmonary disease or emphysema (42%), CF (18%), α1-antitrypsin deficiency (14%), idiopathic pulmonary fibrosis (12%), or PPH (6%). To be eligible for bilateral lung transplantation, potential transplant recipients should be without significant comorbid disease. Patients with emphysema generally are older than other patient groups (e.g., CF) and thus perhaps are more at risk for cardiovascular or cerebrovascular events. In contrast, CF patients often have occult renal insufficiency secondary to years of antibiotic therapy, particularly with aminoglycosides. Unique infectious concerns are also seen in the CF population because these patients frequently are infected with one or more strains of Pseudomonas aeruginosa and often are colonized with mycobacterial or fungal pathogens. Furthermore, CF patients often have a degree of liver disease, pancreatic insufficiency, or both owing to the multi-organ-system effects of the CF genetic defect. ...

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