The evolution of techniques and indications for lung transplantation.

The techniques and indications for lung transplantation have evolved significantly in the past 6 years. We initially restricted single-lung transplantation to patients with pulmonary fibrosis and developed the double-lung transplantation procedure for patients with emphysema or cystic fibrosis. However, with the double-lung procedure, a 25% mortality rate resulted from ischemic complications at the tracheal anastomosis. The technique was altered to incorporate bilateral bronchial anastomosis, with a resulting reduction in airway complications. The double-lung transplantation procedure continued to have significant drawbacks, including intraoperative and postoperative hemorrhage, and cardiac complications due to prolonged cardiopulmonary bypass, ischemic cardiac arrest, and extensive manipulation of the heart. These problems recently have been addressed with a much simplified procedure incorporating a bilateral transverse thoracosternotomy, replacement of the right lung without cardiopulmonary bypass, and replacement of the left lung with or without a short period of partial bypass. This procedure has been successfully used for emphysema and for cystic fibrosis. The technique of single-lung transplantation also has been simplified and indications have been expanded to include selected patients with emphysema and with primary pulmonary hypertension. With single-lung transplantation, each of the lungs from a donor has been successfully used for a separate recipient on several occasions, improving the supply of available donor organs.