Heart-lung transplantation is type of surgery in which diseased heart and lungs are removed and replaced by a healthy donor heart and lungs. It remains a complex procedure that is done to only patients who have terminal chronic health conditions involving both the heart, and the lungs when other treatments have been exhausted or are inconceivable.
Indications
Pulmonary Hypertension (PH) that is associated with Right Heart Failure:
Idiopathic Pulmonary Arterial Hypertension (IPAH): The severe case that failed to respond to treatment.
Eisenmenger Syndrome: Reversible pulmonary hypertension that is secondary to congenital heart disease with severe and irreversible pulmonary vascular disease and severe right sided heart failure.
Congenital heart disease secondary to pulmonary vascular disease (IPVD which is an irreversible condition):
Eisenmenger syndrome in conjunction with complex congenital heart disease.
CHD with failing Fontan circulation where heart-lung replacement is the best option.
End Stage Lung Disease Along with Severe Cardiac Disease:
Cystic Fibrosis or Interstitial Lung Disease (ILD): when used with pulmonary hypertension or in case of heart failure.
Chronic Obstructive Pulmonary Disease (COPD): With concomitant heart failure or pulmonary hypertension.
Pulmonary Fibrosis with resultant heart disease:
It is referred to as End-Stage Cardiac Disease with Severe Pulmonary Involvement.
Cardiac Disease with Secondary Pulmonary Hypertension:
When pulmonary vascular resistance is too high for isolated heart transplantation.
Difficult cases of cardiomyopathies associated with irreversibility changes in pulmonary vasculature.
Contraindications
Age: The risk may be elevated with older age (>65–70 years) but does not completely preclude participation in healthy older adults.
History of Malignancy: Thus, cancer in remission may be acceptable, but the recurrence risk is always assessed individually.
Active infection: Continuous undetected inflammatory diseases or state such as sepsis.
Outcomes
Equipment
Cardiopulmonary Bypass (CPB) Machine
Ventilation and Anesthesia Equipment
ECMO (Extracorporeal Membrane Oxygenation) System
Organ Preservation Systems
Patient preparation
Medical Evaluation:
Diagnostic Tests: Electrocardiogram, echocardiogram, cardiac catheterization, pulmonary functioning test, CT scan, MRI, and other imaging.
Blood Tests: To monitor the functioning of various organs, for infection diagnosis or absence, and to match regarding blood type or HLA typing.
Nutritional Assessment: Some steps searches for optimization the patient’s diet; consultation concerning malnutrition or obesity.
Medications: Treatment of symptoms associated with heart and lung failure.
Prophylactic antibiotics or antiviral therapy depending on the agents that are likely to precipitate infection.
Medications for severe pulmonary hypertension or pulmonary hypertension associated with heart diseases.
Oxygen and Ventilation: Supplemental oxygen, if needed, or non-invasive ventilation if needed.
Patient position
Supine Position: The patient is positioned supine, placing them flat on their back, on the operating table. This is a typical position for thoracic surgeries, including heart, lung transplants.
Chest Exposure: A patient is typically placed in a slightly elevated position (Trendelenburg or reverse Trendelenburg) to maximize exposure of the thoracic cavity for surgical procedures and to prevent venous congestion. A sternotomy or clamshell incision is employed, so the patient’s chest must be completely open.
Preoperative Phase Assessment and Matching
Complete assessment of the condition of the recipient.
Availability of an organ donor with the same blood group, an appropriate size of the organ and low rejection risk.
Donor Organ Procurement: The donor’s heart and lungs are retrieved as a single block.
Special handling by protecting the organs from ischemic injury through cold perfusion solutions and packing in sterile bags.
Recipient Preparation: General anesthesia is given into the patient.
Central venous lines, arterial lines, and a Foley catheter are placed.
The patient is placed on ventilator to promote adequate oxygenation.
Surgical Technique
Initial Incision and Exposure: The major surgery as median sternotomy is done, which is a straight incision made on the sternum. The anterior thoracic wall is incised, thereby exposing the contents of the chest cavity, that is the heart and the lungs.
Cardiopulmonary Bypass (CPB): The patient is prepared for CPB, during surgery the heart and lung function is replaced by a heart-lung machine. Cannulas are inserted into major vessels to allow blood to be diverted into the machine.
Excision of Diseased Organs
The native lungs and heart are then slowly and meticulously dissected.
Pulmonary artery, aorta, superior vena cava (SVC), inferior vena cava (IVC), trachea are branch out.
Implantation of Donor Organs:
Lung Transplantation: The donor trachea Intervertebral disc is sutured to the recipient trachea Intervertebral disc.
The pulmonary arteries and veins are joined (connected by sutures) to the similar vessels of the recipient.
Heart Transplantation: Donor’s left atrium, right atrium, aorta and pulmonary artery is transected and anastomosed to the corresponding recipient’s structures.
Sequential Anastomoses: The surgical team ensures no more bleeding and perfect seal off at each point of anastomosis that has been done.
Post-implantation Phase
Weaning Off Cardiopulmonary Bypass:
Gradual weaning from CPB while monitoring cardiac and pulmonary function.
Administration of medications to support blood pressure and heart rate.
Closure: Chest drains are inserted to evacuate air & fluids.
The sternum is closed then wired, and the skin incision is sutured.
Complications
Infections:
High risk due to immunosuppressive therapy.
Common pathogens: Bacteria (e.g., Staphylococcus aureus), fungi (e.g., Aspergillus), and viruses (e.g., CMV). Bleeding and Vascular Complications:
Caused by surgical anastomosis or coagulation abnormalities from pre-existing conditions or bypass use during surgery. Rejection:
Rapid and uncommon; caused by pre-existing antibodies.
Acute cellular or antibody-mediated rejection within days to weeks.
Chronic Rejection (Chronic Graft Dysfunction) Bronchiolitis obliterans syndrome(BOS): Lung involvement that presents with progressive airflow limitation. Coronary allograft vasculopathy (CAV): Impacting the heart; it causes ischemic changes. Infection
Risk continues even later by viral late infections like CMV, EBV, or fungal. Malignancies Post-transplant lymphoproliferative disorder (PTLD): It is related to EBV activation.
Skin cancers and other malignancies because of immunosuppression.
Heart-lung transplantation is type of surgery in which diseased heart and lungs are removed and replaced by a healthy donor heart and lungs. It remains a complex procedure that is done to only patients who have terminal chronic health conditions involving both the heart, and the lungs when other treatments have been exhausted or are inconceivable.
Pulmonary Hypertension (PH) that is associated with Right Heart Failure:
Idiopathic Pulmonary Arterial Hypertension (IPAH): The severe case that failed to respond to treatment.
Eisenmenger Syndrome: Reversible pulmonary hypertension that is secondary to congenital heart disease with severe and irreversible pulmonary vascular disease and severe right sided heart failure.
Congenital heart disease secondary to pulmonary vascular disease (IPVD which is an irreversible condition):
Eisenmenger syndrome in conjunction with complex congenital heart disease.
CHD with failing Fontan circulation where heart-lung replacement is the best option.
End Stage Lung Disease Along with Severe Cardiac Disease:
Cystic Fibrosis or Interstitial Lung Disease (ILD): when used with pulmonary hypertension or in case of heart failure.
Chronic Obstructive Pulmonary Disease (COPD): With concomitant heart failure or pulmonary hypertension.
Pulmonary Fibrosis with resultant heart disease:
It is referred to as End-Stage Cardiac Disease with Severe Pulmonary Involvement.
Cardiac Disease with Secondary Pulmonary Hypertension:
When pulmonary vascular resistance is too high for isolated heart transplantation.
Difficult cases of cardiomyopathies associated with irreversibility changes in pulmonary vasculature.
Age: The risk may be elevated with older age (>65–70 years) but does not completely preclude participation in healthy older adults.
History of Malignancy: Thus, cancer in remission may be acceptable, but the recurrence risk is always assessed individually.
Active infection: Continuous undetected inflammatory diseases or state such as sepsis.
Cardiopulmonary Bypass (CPB) Machine
Ventilation and Anesthesia Equipment
ECMO (Extracorporeal Membrane Oxygenation) System
Organ Preservation Systems
Patient preparation
Medical Evaluation:
Diagnostic Tests: Electrocardiogram, echocardiogram, cardiac catheterization, pulmonary functioning test, CT scan, MRI, and other imaging.
Blood Tests: To monitor the functioning of various organs, for infection diagnosis or absence, and to match regarding blood type or HLA typing.
Nutritional Assessment: Some steps searches for optimization the patient’s diet; consultation concerning malnutrition or obesity.
Medications: Treatment of symptoms associated with heart and lung failure.
Prophylactic antibiotics or antiviral therapy depending on the agents that are likely to precipitate infection.
Medications for severe pulmonary hypertension or pulmonary hypertension associated with heart diseases.
Oxygen and Ventilation: Supplemental oxygen, if needed, or non-invasive ventilation if needed.
Patient position
Supine Position: The patient is positioned supine, placing them flat on their back, on the operating table. This is a typical position for thoracic surgeries, including heart, lung transplants.
Chest Exposure: A patient is typically placed in a slightly elevated position (Trendelenburg or reverse Trendelenburg) to maximize exposure of the thoracic cavity for surgical procedures and to prevent venous congestion. A sternotomy or clamshell incision is employed, so the patient’s chest must be completely open.
Complete assessment of the condition of the recipient.
Availability of an organ donor with the same blood group, an appropriate size of the organ and low rejection risk.
Donor Organ Procurement: The donor’s heart and lungs are retrieved as a single block.
Special handling by protecting the organs from ischemic injury through cold perfusion solutions and packing in sterile bags.
Recipient Preparation: General anesthesia is given into the patient.
Central venous lines, arterial lines, and a Foley catheter are placed.
The patient is placed on ventilator to promote adequate oxygenation.
Initial Incision and Exposure: The major surgery as median sternotomy is done, which is a straight incision made on the sternum. The anterior thoracic wall is incised, thereby exposing the contents of the chest cavity, that is the heart and the lungs.
Cardiopulmonary Bypass (CPB): The patient is prepared for CPB, during surgery the heart and lung function is replaced by a heart-lung machine. Cannulas are inserted into major vessels to allow blood to be diverted into the machine.
The native lungs and heart are then slowly and meticulously dissected.
Pulmonary artery, aorta, superior vena cava (SVC), inferior vena cava (IVC), trachea are branch out.
Implantation of Donor Organs:
Lung Transplantation: The donor trachea Intervertebral disc is sutured to the recipient trachea Intervertebral disc.
The pulmonary arteries and veins are joined (connected by sutures) to the similar vessels of the recipient.
Heart Transplantation: Donor’s left atrium, right atrium, aorta and pulmonary artery is transected and anastomosed to the corresponding recipient’s structures.
Sequential Anastomoses: The surgical team ensures no more bleeding and perfect seal off at each point of anastomosis that has been done.
Weaning Off Cardiopulmonary Bypass:
Gradual weaning from CPB while monitoring cardiac and pulmonary function.
Administration of medications to support blood pressure and heart rate.
Closure: Chest drains are inserted to evacuate air & fluids.
The sternum is closed then wired, and the skin incision is sutured.
Complications
Infections:
High risk due to immunosuppressive therapy.
Common pathogens: Bacteria (e.g., Staphylococcus aureus), fungi (e.g., Aspergillus), and viruses (e.g., CMV). Bleeding and Vascular Complications:
Caused by surgical anastomosis or coagulation abnormalities from pre-existing conditions or bypass use during surgery. Rejection:
Rapid and uncommon; caused by pre-existing antibodies.
Acute cellular or antibody-mediated rejection within days to weeks.
Chronic Rejection (Chronic Graft Dysfunction) Bronchiolitis obliterans syndrome(BOS): Lung involvement that presents with progressive airflow limitation. Coronary allograft vasculopathy (CAV): Impacting the heart; it causes ischemic changes. Infection
Risk continues even later by viral late infections like CMV, EBV, or fungal. Malignancies Post-transplant lymphoproliferative disorder (PTLD): It is related to EBV activation.
Skin cancers and other malignancies because of immunosuppression.
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