100 QUESTIONS IN CARDIOLOGY

59 Who is eligible for a heart or heart-lung

transplant? How do I assess suitability for

transplantation?

Brendan Madden

Cardiac and pulmonary transplantation are potential options for

selected patients with end stage cardiac or pulmonary disease,

unresponsive to conventional medical or surgical therapies. The

majority of patients referred for cardiac transplantation have end

stage cardiac failure as a consequence of ischaemic heart disease

or cardiomyopathy, although some patients are referred whose

cardiac failure follows valvular or congenital heart disease. There

are four lung transplant procedures, namely, heart-lung trans-

plantation, bilateral lung transplantation, single lung trans-

plantation and living related lobar transplantation.

With increasing numbers of centres performing cardiac trans-

plantation worldwide, fewer combined heart-lung transplant proce-

dures are being performed. Therefore, the indications for this

operation have been redefined and by and large, heart and lung

transplantation is now reserved for patients with Eisenmenger

syndrome who have a surgically incorrectable cardiac defect. Broadly

speaking, patients with suppurative lung disease, e.g. cystic fibrosis

and bronchiectasis, require bilateral lung transplantation. Single

lung transplantation is usually inappropriate for this group because

of the concern of contamination of the allograft from sputum overspill

from the native remaining lung in an immunocompromised patient.

Single lung transplantation has been successfully applied to patients

with end stage respiratory failure due to restrictive lung conditions,

e.g. pulmonary fibrosis, and to selected patients with emphysema. In

living related lobar transplantation a lower lobe is taken from two

living related donors, the transplant recipient undergoes bilateral

pneumonectomy and subsequent re-implantation of a lower lobe

into each hemithorax. Encouraging results for this procedure have

been described in adolescents with cystic fibrosis.

Cardiac transplantation – indications

11 Prognosis less than 12 months

22 Inability to lead a satisfactory life because of physical limitation

caused by cardiac failure