Combined heart and lung transplant (HLTx) is an effective procedure for patients with end-stage heart and lung disease. The first recipients of HLTx were patients with pulmonary hypertension and cystic fibrosis. As isolated heart and lung transplant has matured, current indications are the following:

Contraindications are similar to lung transplantation in that patients with history of malignancy within the last 5 years, active tobacco use, advanced renal or hepatic disease, and severe untreatable infections should not be offered HLTx. As perioperative management has improved, there are several relative contraindications:

Age: Due to the magnitude of the operation, we do not consider patients over the age of 60. The oldest patient to undergo HLTx in the United States since 2000 was 69. Certainly, some patients may be physiologically younger than their chronologic age.

Obesity: Perioperative survival appears to be lower in patients with a BMI >30. But as with age, this is a relative contraindication and some patients may have an elevated BMI but preserved muscle mass.

Severe esophageal or pharyngeal dysfunction: It is increasingly clear that swallowing abnormalities before and after transplant contribute to chronic pulmonary dysfunction. The exact mechanism is unclear but uncorrectable gastroesophageal reflux or esophageal dysmotility may lead to chronic aspiration and allograft injury.

Deconditioning and functional status: Preoperative conditioning and functional status are critical predictor of 1-year outcome. As in lung transplantation, candidates should be subjected to intense physical therapy and rehabilitation. Moreover, when patients are unable to participate in rehabilitation due to their lung disease, most centers will initiate extracorporeal membrane oxygenation (ECMO) rather than pursue transplantation.

Preoperative planning requires a multidisciplinary approach to exclude reversible causes of cardiopulmonary disease and determine if a candidate could be well served with isolated cardiac or pulmonary transplant. A complete evaluation includes imaging (CT of chest, abdomen and pelvis), cancer screening, and full social and financial evaluation. Patients with prior palliative operations like central shunts or major pulmonary collaterals should have appropriate imaging to help with the cardiectomy and pneumonectomy. Potts shunts (left PA [pulmonary artery] to descending aorta), for example, can be difficult to mobilize, dissect, and control. Pulmonary collaterals can be associated with severe bleeding during the explant. It may be necessary to utilize a short period of circulatory arrest to successfully explant the heart and lungs on some patients. Thus, preoperative imaging is critically important.