Heart-Lung Transplantation

Updated: May 09, 2022
  • Author: Mary C Mancini, MD, PhD, MMM; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Practice Essentials

Heart-lung transplantation (cardiopulmonary transplantation) is the simultaneous surgical replacement of the heart and lungs in patients with end-stage cardiac and pulmonary disease. [1, 2, 3]  This procedure remains a viable therapeutic alternative for patients in specific disease states, though its use has substantially diminished in recent years. [4]

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

Early clinical applications of heart-lung transplantation 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.

Discoveries and advancements in cardiac transplantation were eventually 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. With this new immunosuppressive agent, rejection could be controlled with less steroid use. This development addressed the difficulties incurred in healing of the partially devascularized trachea and constituted a critical step in the reduction of postoperative morbidity and mortality. By capitalizing on these significant advances, human heart-lung transplantation reemerged as a therapeutic alternative for end-stage cardiopulmonary disease.

Candidates for heart-lung transplantation are generally younger persons with a fatal disease. The transplantation process offers hope to these persons. However, the shortage of donor organs makes this lifesaving procedure unavailable to many individuals. Both patients and families need strong physician support, availability, and candor when dealing with issues as they arise.



Idiopathic pulmonary arterial hypertension (IPAH) was the main indication for heart-lung transplantation in the 1980s. However, double-lung transplantation became the preferred option for end-stage IPAH when studies showed that this procedure led to resolution of right ventricular dysfunction. [5] Currently, the main indication for heart-lung transplantation is congenital heart disease (CHD), followed by acquired heart disease combined with pulmonary hypertension and/or intrinsic lung disease. [6]  

Heart-lung transplantation is indicated in patients who have end-stage disease of both the heart and the 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, and truncus arteriosus) are considered candidates for the procedure.

However, a retrospective review of transplantation in 442 adults with Eisenmenger syndrome found that outcomes varied according to the type of septal defect present. In patients with atrial septal defect, survival rates were better with double-lung transplantation than with heart-lung transplantation, whereas in patients with ventricular septal defect, survival rates were beter with heart-lung transplantation than with double-lung transplantation. [7]   

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.

Heart-lung transplantation may be indicated for select patients with connective tissue disease (CTD) with pulmonary involvement. [8]



Age may be considered a relative contraindication. 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 on the patient’s physiologic age, rather than the chronologic age. The age of 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.



Between January 1988 and June 2018, 4128 heart-lung transplantations were reported to the International Society of Heart and Lung Transplantation (ISHLT). The annual number of heart-lung transplantations reported in the last 5 years has been below 60. Between 2010 and June 2018 only 33.7% of reporting centers had performed at least 1 heart-lung transplantation. The ISHLT reports adult recipients surviving the first year had a median survival of 12.8 years. [4]

The 1-year survival rate after a heart-lung transplant is 65%; the 5-year survival rate is 40%. Early mortality is secondary to surgical losses and acute allograft failure. The late attrition is due to obliterative bronchiolitis and rejection. [9]