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INTRODUCTION

Lung transplantation offers patients with end-stage lung disease hope for a second chance at life. More than 55,000 cases have been reported to the International Society for Heart and Lung Transplantation Registry since 1985.1 The potential options, in order of greatest frequency, are double-lung, single-lung, heart-lung, and lobar transplants (Fig. 110-1). Denton A. Cooley described the first successful heart-lung transplant in 1968 in a 2-month-old girl with congestive heart failure and recurrent pneumonia.2 This dual-organ procedure evolved into the more commonly used bilateral sequential lung transplant described by Alec Patterson, Joel D. Cooper, and their colleagues from the University of Toronto.3 The Toronto Lung Group popularized the technique of single-lung transplantation in 1986 for patients with pulmonary fibrosis, and this has become an important option for many patients.4

Figure 110-1

Types of lung transplantation: single, double, heart-lung, and lobar.

Today, highly specialized centers with multidisciplinary teams that include thoracic and cardiac surgeons, pulmonologists, coordinators, intensivists, and medical specialists orchestrate more than 4000 lung transplants annually. In addition, lung transplantation is highly regulated, with an emphasis on cost, quality, and outcomes reporting. In the United States, the United Network for Organ Sharing (UNOS) oversees program quality metrics and sets the bar for performance standards. Throughout Europe, a variety of regional oversight organizations ensure appropriateness of donor allocation and outcomes.

The field has seen a significant increase in the prevalence of diseases that are treatable with a lung transplant. These include chronic obstructive pulmonary disease (COPD) with or without alpha-1 antitrypsin deficiency (AATD); bronchiectasis with or without cystic fibrosis (CF); pulmonary vascular diseases, including chronic thromboembolic disorders and idiopathic pulmonary arterial hypertension; interstitial lung disease with or without idiopathic interstitial pneumonia; and rarer entities such as bronchiolitis obliterans syndrome (BOS), graft versus host disease (GVHD), primary ciliary dyskinesia (PCD), adult congenital heart and lung disease, lymphangioleiomyomatosis (LAM), and infectious and malignant disorders.

Long-term survival has gradually improved over the years, primarily because short-term survival has improved. Worldwide, however, the 5-year survival rate remains close to 55% because of chronic lung allograft dysfunction (CLAD).5 Patients who survive the first year after transplantation have a median survival of 8 years.

The patient population for lung transplantation has become increasingly old and ill. The lung allocation score (LAS) in the United States and the high-urgency status in Europe prioritize waitlisted patients such that the sickest patients receive transplants first. This has had the paradoxic effect of decreasing mortality, especially among patients with LAS > 50, at the expense of challenging our efforts to improve 1-year survival. Use of preoperative extracorporeal membrane oxygenation (ECMO) and inpatient status before transplant are becoming more common, suggesting that the transplant population is becoming sicker. The gradual improvements in mortality despite this trend are commendable and likely reflect improvements ...

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