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Key Concepts

  • Epidemiology

    • To date, more than 30,000 lung and 2600 heart–lung transplantations have been reported to the International Society of Heart and Lung Transplant Registry. Since 2005, bilateral lung transplant has been the most commonly performed procedure.

  • Pathophysiology

    • Lung and heart–lung transplantation is performed for patients who have end-stage cardiopulmonary disease with no contraindications and have the potential to be rehabilitated completely. Most lung transplants are done for chronic obstructive pulmonary disease (COPD), cystic fibrosis, idiopathic pulmonary fibrosis, and pulmonary hypertension. Primary pulmonary hypertension and Eisenmenger syndrome are the most common indications for heart–lung transplantation.

  • Clinical features

    • Candidates typically experience severe dyspnea, cyanosis, hemoptysis, or multiple hospitalizations and have New York Heart Association functional class III and IV status. Lung transplant candidates typically have a life expectancy of 24 to 36 months and are usually less than 75 years of age. Patients with COPD generally have a forced expiratory volume in 1 second (FEV1) of less than 20 percent predicted, whereas patients with cystic fibrosis usually have an FEV1 of less than 30 percent predicted, an increasing oxygen requirement, nutritional decline, and an increasing requirement for hospitalization. Patients with interstitial lung diseases may have a rapidly progressive decline with increasing oxygen requirements and reduced vital capacity. Candidates for heart–lung transplant have both pulmonary and cardiac disease and are typically under 65 years of age.

  • Diagnostics

    • Candidates for lung and heart–lung transplants undergo an extensive workup to evaluate underlying cardiopulmonary function and exclude malignancy, active infection, end-organ dysfunction, and vascular disease. Diagnostic modalities include pulmonary function tests, endoscopy (especially bronchoscopy), echocardiography, cardiac catheterization, duplex ultrasonography, computed tomography and/or magnetic resonance imaging, serologic screens, and metabolic panels.

  • Treatment

    • Lung transplantation: COPD, cystic fibrosis, idiopathic pulmonary fibrosis, and pulmonary hypertension.

    • Heart–lung transplantation: Eisenmenger syndrome, sarcoid with both cardiac and pulmonary involvement.

  • Outcomes

    • Lung transplant survival rates are 82, 55, and 30 percent at 1, 5, and 10 years, respectively; best survival rates are among patients with cystic fibrosis. Significant spirometric improvement is immediate and plateaus at 6 to 12 months. For heart–lung transplantation, survival rates are 71 percent at 1 year. Early morbidity and mortality stem from technical complications, infections, and graft failure. Late complications are usually manifestations of bronchiolitis obliterans and malignancy.


Lung and heart–lung transplantation has emerged over the past several decades as an acceptable therapy for end-stage lung disease. Despite significant progress, lung transplantation remains a complex therapy that requires a multidisciplinary approach for successful outcomes. Moreover, it is increasingly clear that early postoperative events are associated with long-term complications. There are currently approximately 1800 and 70 patients awaiting lung and heart–lung transplant, respectively. In 2009, 1599 adult lung transplants were performed in the United States. In 2005, a new allocation policy was adopted in the United States. Patients are now assigned a Lung Allocation Score (LAS) based on clinical parameters. The score emphasizes transplant utility rather than wait-list ...

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