eMedicine Specialties > Transplantation > Surgery

Heart-Lung Transplantation

Author: Mary C Mancini, MD, PhD, Professor, Department of Surgery, Louisiana State University Health Sciences Center
Contributor Information and Disclosures

Updated: Nov 5, 2008

Introduction

Background

Cardiopulmonary transplantation (heart and lung transplantation) is the simultaneous surgical replacement of the heart and lungs in patients with end-stage cardiac and pulmonary disease. This procedure remains a viable therapeutic alternative for patients in specific disease states, although the frequency of application has substantially diminished in recent years. For more information, visit Medscape's Heart-Lung Transplantation Resource Center.

Historical perspective

In Russia during the 1940s, Demikhov performed experimental heart and lung transplants in subprimate species. These procedures were performed without the benefit of hypothermia or cardiopulmonary bypass. The early experience with the procedure in subprimate species suggested that intact pulmonary innervation was needed to maintain normal respiratory patterns and drive. Complete denervation of the heart-lung block led to a diminished respiratory rate, increased tidal volumes, apneic periods, and death.

Subsequent experiments with primates demonstrated significant variation among species with respect to denervation of the allograft block and established that complete cardiopulmonary denervation was compatible with normal respiratory function and long-term survival in primates but not in lower mammals.

These discoveries led to the first human heart-lung transplant, which was performed by Denton Cooley and his team in 1968 on a 2-month-old infant with a complete atrioventricular canal defect and pulmonary hypertension.1 This and other early clinical applications of the procedure met with poor results secondary to poor patient selection, inexperience with preservation methods, insufficient understanding of pulmonary physiology, and primitive methods of immunosuppression. These early and disappointing clinical results confined the procedure to the laboratory until other areas of transplantation biology advanced.

In 1972, Castaneda et al performed a series of cardiopulmonary autotransplantation procedures on baboons, demonstrating that both the procedure and autograft denervation were compatible with long-term survival.2,3 Discoveries and advancements in cardiac transplantation over the same time period were applied to heart-lung transplantation, including the development of rabbit antithymocyte globulin to deter rejection and endomyocardial biopsy techniques to detect rejection.

The discovery and application of cyclosporine A was a turning point in the field. With this new immunosuppressive agent, rejection could be controlled with less steroid use, thus addressing the difficulties incurred in healing of the partially devascularized trachea and constituting a critical step in the reduction of postoperative morbidity and mortality. By capitalizing on these significant advances, human heart-lung transplantation reappeared as a therapeutic alternative for end-stage cardiopulmonary disease.

Pathophysiology

Heart-lung transplantation is indicated in patients who have end-stage disease of both the heart and lungs. Patients with complex congenital heart defects that are not amenable to conventional repair and patients with Eisenmenger syndrome (ie, atrioventricular canal defect, transposition of the great vessels, truncus arteriosus) are considered candidates for the procedure.

Patients with irreversible right-heart failure secondary to pulmonary hypertension may also require total cardiopulmonary replacement. Patients with cystic fibrosis and end-stage bronchiectasis require replacement of both lungs to avoid the complications of allograft contamination. The best treatment for these patients is double-lung transplantation; however, in patients with compromised cardiac function, a heart-lung transplant is indicated.

Frequency

United States

Between January 2006 and January 2007, 37 heart-lung transplantations were reported to the International Society for Heart and Lung Transplantation.4

International

More than 2500 heart-lung transplantations were reported to the International Society of Heart and Lung Transplantation between January 1982 and June 2007.4 Between 2003 and 2008, approximately 50-100 such transplantations were reported annually.4

Mortality/Morbidity

The 1-year survival rate after heart-lung transplantation is 65%; the 5-year survival rate is 40%.

Sex

Incidence is approximately equal in males and females.

Age

  • The lower age limit of candidates for heart-lung transplantation is not defined and is limited only by the availability of donors of suitable size.
  • The upper age limit depends upon the patient's physiologic rather than chronologic age. Age 60 years is the conventional upper limit for most candidates; however, centers with more experience evaluate patients older than 60 years on an individual basis.

Clinical

History

  • Patients who are being considered for heart-lung transplantation undergo a rigorous screening process to assess their overall physical and psychological health. A thorough history is obtained, which includes inquiries regarding the following factors:
    • Cardiopulmonary disease history
    • Infectious disease exposure
    • Environmental exposure
    • Genetic history
    • Family history
    • Social history, including a substance-abuse profile
  • All potential candidates are evaluated by social services specialists in order to ensure access to required medications and initiation of appropriate planning.

Physical

A complete physical examination is performed, with particular attention to signs of concomitant disease processes, including GI disturbances, bleeding, vascular insufficiency, and occult carcinoma.

Causes

Causes of end-stage cardiopulmonary failure that necessitate cardiopulmonary transplantation range from congenital cardiac disease to idiopathic causes, and include the following:

  • Irreparable congenital cardiac anomalies with pulmonary hypertension (Eisenmenger complex)
  • Primary pulmonary hypertension with irreversible right heart failure
  • Sarcoidosis involving only the heart and lungs

More on Heart-Lung Transplantation

Overview: Heart-Lung Transplantation
Differential Diagnoses & Workup: Heart-Lung Transplantation
Treatment & Medication: Heart-Lung Transplantation
Follow-up: Heart-Lung Transplantation
Multimedia: Heart-Lung Transplantation
References
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References

  1. Cooley DA, Bloodwell RD, Hallman GL, et al. Organ transplantation for advanced cardiopulmonary disease. Ann Thorac Surg. Jul 1969;8(1):30-46. [Medline].

  2. Castaneda AR, Arnar O, Schmidt-Habelman P, et al. Cardiopulmonary autotransplantation in primates. J Cardiovasc Surg (Torino). Sep-Oct 1972;13(5):523-31. [Medline].

  3. Castaneda AR, Zamora R, Schmidt-Habelmann P, et al. Cardiopulmonary autotransplantation in primates (baboons): late functional results. Surgery. Dec 1972;72(6):1064-70. [Medline].

  4. Hertz MI, Aurora P, Christie JD, et al. Registry of the International Society for Heart and Lung Transplantation: a quarter century of thoracic transplantation. J Heart Lung Transplant. Sep 2008;27(9):937-42. [Medline].

  5. Griffith BP, Hardesty RL, Trento A, Bahnson HT. Asynchronous rejection of heart and lungs following cardiopulmonary transplantation. Ann Thorac Surg. Nov 1985;40(5):488-93. [Medline].

  6. Belperio JA, Lake K, Tazelaar H, et al. Bronchiolitis obliterans syndrome complicating lung or heart-lung transplantation. Semin Respir Crit Care Med. Oct 2003;24(5):499-530. [Medline].

  7. Trulock EP. Lung and heart-lung transplantation: overview of results. Semin Respir Crit Care Med. Oct 2001;22(5):479-88. [Medline].

  8. Borel JF. Cyclosporin-A--present experimental status. Transplant Proc. Mar 1981;13(1 Pt 1):344-8. [Medline].

  9. Burton CM, Milman N, Carlsen J, et al. The Copenhagen National Lung Transplant Group: survival after single lung, double lung, and heart-lung transplantation. J Heart Lung Transplant. Nov 2005;24(11):1834-43. [Medline].

  10. Caves PK, Stinson EB, Billingham M, Shumway NE. Percutaneous transvenous endomyocardial biopsy in human heart recipients. Experience with a new technique. Ann Thorac Surg. Oct 1973;16(4):325-36. [Medline].

  11. Cooper DK. Transplantation of the heart and both lungs. I. Historical review. Thorax. Jul 1969;24(4):383-90. [Medline].

  12. Cooper JD. Herbert Sloan lecture. Lung transplantation. Ann Thorac Surg. Jan 1989;47(1):28-44. [Medline].

  13. Dew MA, DiMartini AF. Psychological disorders and distress after adult cardiothoracic transplantation. J Cardiovasc Nurs. Sep-Oct 2005;20(5 Suppl):S51-66. [Medline].

  14. Grady KL, Lanuza DM. Physical functional outcomes after cardiothoracic transplantation. J Cardiovasc Nurs. Sep-Oct 2005;20(5 Suppl):S43-50. [Medline].

  15. Harjula A, Baldwin JC, Starnes VA, et al. Proper donor selection for heart-lung transplantation. The Stanford experience. J Thorac Cardiovasc Surg. Dec 1987;94(6):874-80. [Medline].

  16. Hosenpud JD, Bennett LE, Keck BM, et al. The Registry of the International Society for Heart and Lung Transplantation: sixteenth official report--1999. J Heart Lung Transplant. Jul 1999;18(7):611-26. [Medline].

  17. Jamieson SW, Burton NA, Bieber CP, et al. Cardiac-allograft survival in primates treated with cyclosporin A. Lancet. Mar 10 1979;1(8115):545. [Medline].

  18. Jamieson SW, Stinson EB, Oyer PE, et al. Operative technique for heart-lung transplantation. J Thorac Cardiovasc Surg. Jun 1984;87(6):930-5. [Medline].

  19. Lee SH, Rubin LJ. Current treatment strategies for pulmonary arterial hypertension. J Intern Med. Sep 2005;258(3):199-215. [Medline].

  20. Longmore DB, Cooper DK, Hall RW, et al. Transplantation of the heart and both lungs. II. Experimental cardiopulmonary transplantation. Thorax. Jul 1969;24(4):391-8. [Medline].

  21. Lower RR, Stofer RC, Hurley EJ, Shumway NE. Complete homograft replacement of the heart and both lungs. Surgery. Nov 1961;50:842-5. [Medline].

  22. McCarthy PM, Kirby TJ, White RD, et al. Lung and heart-lung transplantation: the state of the art. Cleve Clin J Med. May-Jun 1992;59(3):307-16. [Medline].

  23. McCarthy PM, Starnes VA, Theodore J, et al. Improved survival after heart-lung transplantation. J Thorac Cardiovasc Surg. Jan 1990;99(1):54-9; discussion 59-60. [Medline].

  24. Nakae S, Webb WR, Theodorides T, Sugg WL. Respiratory function following cardiopulmonary denervation in dog, cat, and monkey. Surg Gynecol Obstet. Dec 1967;125(6):1285-92. [Medline].

  25. Patterson GA, Todd TR, Cooper JD, et al. Airway complications after double lung transplantation. Toronto Lung Transplant Group. J Thorac Cardiovasc Surg. Jan 1990;99(1):14-20; discussion 20-1. [Medline].

  26. Pinderski LJ, Kirklin JK, McGiffin D, et al. Multi-organ transplantation: is there a protective effect against acute and chronic rejection?. J Heart Lung Transplant. Nov 2005;24(11):1828-33. [Medline].

  27. Reitz BA, Wallwork JL, Hunt SA, et al. Heart-lung transplantation: successful therapy for patients with pulmonary vascular disease. N Engl J Med. Mar 11 1982;306(10):557-64. [Medline].

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Further Reading

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Keywords

heart lung transplantation, heart lung transplant, heart-lung transplant, cardiopulmonary replacement, cardiopulmonary transplantation, cardiopulmonary allograft, heart-lung allograft, double-lung transplantation, end-stage cardiac disease, end-stage pulmonary disease, end-stage cardiopulmonary disease, Denton Cooley, cyclosporine A, immunosuppression, immunosuppressives, Eisenmenger syndrome, congenital heart defects, cystic fibrosis, end-stage bronchiectasis, allograft vascular disease, obliterative bronchiolitis, rejection

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Contributor Information and Disclosures

Author

Mary C Mancini, MD, PhD, Professor, Department of Surgery, Louisiana State University Health Sciences Center
Mary C Mancini, MD, PhD is a member of the following medical societies: American Heart Association, American Medical Association, American Thoracic Society, Association for Academic Surgery, Association for Surgical Education, International College of Surgeons, International Society for Heart and Lung Transplantation, New York Academy of Sciences, Phi Beta Kappa, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.

Medical Editor

Richard Thurer, MD, B and Donald Carlin Professor of Thoracic Surgical Oncology, Miller School of Medicine, University of Miami
Richard Thurer, MD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Medical Association, American Thoracic Society, Florida Medical Association, Society of Surgical Oncology, and Society of Thoracic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Shreekanth V Karwande, MBBS, Chair, Professor, Department of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine and Medical Center
Shreekanth V Karwande, MBBS is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Heart Association, Society of Critical Care Medicine, Society of Thoracic Surgeons, and Western Thoracic Surgical Association
Disclosure: Nothing to disclose.

CME Editor

Michael E Zevitz, MD, Assistant Professor of Medicine, Finch University of the Health Sciences, The Chicago Medical School; Consulting Staff, Private Practice
Michael E Zevitz, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Medical Association, and Michigan State Medical Society
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other; AstraZeneca Grant/research funds Other

 
 
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