Ann Thorac Surg 2001;72:1891
© 2001 The Society of Thoracic Surgeons
Invited commentary
John V. Conte, MDa
a Division of Cardiac Surgery, Johns Hopkins Medical Institutions, Blalock 618, 600 N Wolfe St, Baltimore, MD 21287, USA
e-mail: jconte{at}csurg.jhmi.edu
Combined heart-lung (H-L) transplantation is the least commonly performed solid organ transplant procedure in the world, and perhaps the least understood. This procedure, which was introduced in 1981 at the dawn of the era of lung transplantation was only performed 90 times in 1999 according to the seventeenth report of the International Society for Heart and Lung Transplantation (ISHLT)[1]. This is the nadir reached from a peak of 237 H-L transplants reported to the ISHLT in 1989. This is due in part to the realization that isolated lung transplantation can offer equivalent survival and physiologic recovery for many diseases previously treated with H-L transplantation such as cystic fibrosis and primary pulmonary hypertension. In such situations, utilization of the heart for isolated cardiac transplantation appears morally and ethically appropriate.
The decrease is also due to the misconception that H-L transplantation is particularly morbid with poor outcomes. Experienced groups, such as the authors, have shown that excellent one-year survival of 73% to 74% can be achieved for Eisenmenger and non-Eisenmenger patients. Results such as this are comparable to ISHLT data for isolated lung transplantation for pulmonary hypertension. Furthermore, data from a review of the International Society for Heart and Lung Transplantation/United Network for Organ Sharing (ISHLT/UNOS) Joint Thoracic Registry presented at the Twentieth Annual Meeting of the ISHLT in Osaka, Japan showed that H-L is superior than isolated lung transplantation and cardiac repair for Eisenmenger’s syndrome [2]. Univariate and multivariate analysis revealed that survival following H-L was particularly advantageous in patients with ventricular septal defects and multiple complex congenital anomalies confirming smaller single center reports.
Unfortunately, part of the reason for the decrease in H-L transplantation is the current UNOS allocation system that unfairly disadvantages patients waiting for H-L. The current system, implemented in 1999, shows preference for patients in hospitals awaiting isolated cardiac transplantation. Current discussions at the UNOS thoracic organ committee are seeking to increase the number of organs allocated to status 1A patients in an effort to decrease waiting list mortality. The aim is altruistic, but may further disadvantage those patients whose best option for long term survival is H-L transplantation. It is critically important that policymakers do not unintentionally disadvantage this group of patients, and thereby deny them the procedure most likely to result in their survival.
References
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Hosenpud J.D., Bennett L.E., Keck B.M., et al. The registry of the International Society of Heart and Lung Transplantation: seventeenth official report 2000. J Heart Lung Transplant 2000;19:939-945.[Medline]
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Waddell T.K., Bennett L.E., Kennedy R., et al. Lung or heart-lung transplantation for Eisenmenger’s syndrome: analysis of the ISHLT/UNOS joint thoracic registry. J Heart Lung Transplant 2000;19:57.
