Human lung transplantation, performed as a single lung, double lung, or heart-lung bloc, has emerged as a life-saving procedure for patients with end-stage pulmonary disease. With improvement of operative techniques, organ preservation, and immunosuppressive regimens, combined heart-lung and isolated lung transplantation have become common treatments for patients with a variety of end-stage disease entities. To date, 3466 combined heart-lung transplants and 29,732 lung transplants have been reported worldwide.1 Although the number of heart-lung transplants performed annually has declined in recent years, the number of single lung transplantation procedures remains stable, accompanied by a steady increase in bilateral lung transplant procedures (Fig. 65-1). Clinical progress in thoracic organ transplantation has been considerable, yet significant barriers that limit the scope of these procedures still remain. These include donor organ shortage, limited preservation techniques, graft rejection, and infectious complications. This chapter summarizes the state of the art in combined heart-lung and isolated lung transplantation.
UNOS data representing the number of lung transplant procedures reported by year and procedure type, collected from data reported to the International Society of Heart and Lung Transplantation Registry. This figure may underestimate the total number of procedures worldwide. (From Christie JD, et al: The Registry of the International Society for Heart and Lung Transplantation: Twenty-Sixth Official Adult Lung and Heart-Lung Transplantation Report—2009. J Heart Lung Transplant 2009; 28:1031-1049.)
History of Lung Transplantation
In 1949, Henry Metras described many of the important technical concepts for lung transplantation, including preservation of the left atrial cuff for the pulmonary venous anastomoses and reimplantation of an aortic patch containing the origin of the bronchial arteries to prevent bronchial dehiscence.2 Airway dehiscence was a major obstacle in experimental lung transplantation, and he proposed that preservation of the bronchial arterial supply was critical to airway healing. Unfortunately, this technique was technically cumbersome and never gained widespread popularity. In the 1960s, Blumenstock and Khan advocated transection of the transplant bronchus close to the lung parenchyma to prevent ischemic bronchial necrosis.3 Additional surgical modifications were developed to prevent bronchial anastomotic complications, including telescoping of the bronchial anastomosis, described by Veith in 1970,4 and coverage of the anastomosis with an omental pedicle flap, described by the Toronto group in 1982.5 Corticosteroids were found to be another contributor to poor bronchial healing,6 a problem ameliorated by the introduction of cyclosporine immunosuppression. Thus, by the 1970s, the stage was set for successful lung transplantation in the human.
The first human lung transplant was described in 1963 by Hardy and colleagues at the University of Mississippi.7 The patient, a 58-year-old man with lung cancer, survived 18 days postoperatively. Over the next two decades, nearly 40 lung transplants were performed without long-term success. In 1986, the Toronto Lung Transplant Group reported the first successful series of single lung transplants ...