Lung Transplantation

Introduction

Although experimental lung transplantation (LT) was introduced by the 1940’s and the first human lung transplantation was performed by James Hardy in 1963, successful lung transplantation eluded the lung transplant community for the next two decades until cyclosporine A (CsA) was introduced as a novel immunosuppressant.[1] In 1981, the Stanford group performed the first successful combined heart-lung transplantation and the Toronto Program led by Joel Cooper performed the first successful single lung transplantation in 1983.

Since 1983, surgical and medical advances in donor and recipient management have improved outcomes and lung transplantation is well established as life-saving therapy for end-stage lung disease. This success has been followed by an ever-increasing demand for lung transplantation with increasing numbers of lung transplants performed world-wide. According to the International Society for Heart and Lung Transplantation (ISHLT) registry, over 33891 lung transplants were performed between January 2010 and June 2018. In 2019 more than 4,500 transplants were performed worldwide with over 260 lung transplant centers contributing to this number. [2][3][4]

However, lung transplantation is not yet a perfect solution. It is a complex therapeutic modality that requires high-level surgical and medical expertise and close collaboration with allied health team members. Despite increased transplant activity, we remain unable to meet the demand due to donor shortage. Furthermore, while short-term results have improved, long-term survival after lung transplantation remains unsatisfactory with a median survival of around 6.7 years for patients who received a lung transplant in the the most recent years (2010–June 2017), mainly due development of chronic lung allograft dysfunction (CLAD), the toxicity of the immunosuppressive medications or the ocurrence of solid organ cancer.[5]

The field of lung transplantation continues to evolve. While in the early years deceased donors were young and otherwise healthy and recipients had single-organ failure without comorbidities, the average donor age and prevalence of smoking history have increased, and recipients are also older and may have significant comorbidities such as coronary artery disease. Chronic obstructive pulmonary disease (COPD) has been replaced by interstitial lung disease (ILD) as the leading indication for lung transplantation. We are also now able to bridge very sick patients to transplant using mechanical ventilation and/or extracorporeal life support (ECLS). Improvements in donor management have allowed for expansion of the donor pool and innovations such as ex-vivo lung perfusion (EVLP) enable us to better assess the quality of donor lungs and even improve these lungs through specific therapies.

In this chapter, we will describe the lung transplantation process as a whole. We will discuss recipient selection and preoperative considerations, donor selection, management and allocation, donor and recipient surgery, as well as postoperative recipient management.