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INTRODUCTION

Since its inception in 1963, more than 35,000 lung transplants have been performed globally. For several decades, chronic obstructive pulmonary disease (COPD) was the most common indication for lung transplantation. However, in the United States, the donor lung allocation system has changed the scenario and interstitial lung disease (ILD) is emerging as a more common indication. ILD accounts for about 30% of lung transplants at our center and 33% nationally.1 Cystic fibrosis (CF) is the third most common indication.

To be eligible for bilateral lung transplantation, potential transplant recipients should be without significant comorbidities. Patients with emphysema are generally older than other patient groups (e.g., CF) and, thus perhaps, are more at risk for cardiovascular or cerebrovascular events. Unique infectious considerations such as multidrug-resistant Pseudomonas, Mycobacteria, or fungal colonizations might pose challenges in CF patients. In addition, CF patients may have a degree of liver disease, pancreatic insufficiency, or both owing to the multiorgan system effects of the CF genetic defect. Patients with primary pulmonary hypertension (PPH) may have residual right-sided heart dysfunction immediately after transplantation and need greater attention to cardiac hemodynamics, often requiring an increase of right-sided filling pressures or right ventricular support for hemodynamic stability. Finally, the widespread use of newer vasodilators has permitted many patients with PPH to delay transplantation. Thus, by the time these patients present for transplant, the degree of right-sided heart failure is often quite severe.

CHOICE OF TRANSPLANT

The decision to perform a single-, double-, or heart-lung transplant depends on numerous factors, including recipient characteristics (e.g., disease, age, comorbidities), institutional bias, organ availability, and the urgency of the transplant. Single-lung transplantation is a good option for patients with ILD especially those with idiopathic pulmonary fibrosis.2 Selected patients with emphysema, specifically those of shorter stature and older age, can also expect good results with single-lung transplantation. Unilateral transplantation can also be acceptable for select patients with PPH.3 However, because these cases are challenging and management can be difficult during the first few postoperative days,4 most programs prefer double-lung transplantation for patients with PPH. Double-lung transplant is mandatory for patients with CF and bronchiectasis because, in both cases, the septic native lungs must be excised. When the native disease is accompanied by a preexisting mycetoma5 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 syndrome with PPH and significant left ventricular dysfunction, perhaps owing to an uncorrected congenital defect. The annual rate of heart-lung transplantation has declined significantly 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.6 The different types of lung transplantation ...

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