The current state of lung transplantation.

Editorial The current state of lung transplantation Early attempts at lung transplantation were uniformly unsuccessful.' Many recipients were having assisted ventilation before transplantation and had sepsis with multi-organ failure. The use of high dose cortico-steroids as the principal method of providing early immunosuppression severely affected bronchial healing and frequently led to systemic infection. Acute rejection was difficult to diagnose and often refractory to treatment when recognised. Dehiscence of the airway anastomosis,' related to bronchial ischaemia, was almost invariable in short term survivors and seemed an insuperable problem. The technical difficulties have been largely overcome by approaches that have solved the problem of bronchial healing. Immunosuppression with cyclosporin A allows more selective use ofcorticosteroids in the early postoperative course. Finally, the importance of selection of patients is now recognised and indications for each of the available procedures are being established. Heart-lung transplantation Heart-lung transplantation was introduced for the treatment for pulmonary vascular disease,2 and has become a therapeutic option for a wide range of patients, including those with end stage lung disease.3 Most recipients still have pulmonary vascular disease,4 but the proportion with primary lung disease is increasing and now comprises 40% of all cases, according to the current International Registry.5 Heart-lung transplantation was the first form of lung transplantation to be introduced successfully into clinical practice. A tracheal anastomosis heals much more reliably than a bronchial anastomosis because of the presence of coronary to bronchial collaterals.8 More importantly, it has the advantage that all the diseased pulmonary tissue is removed. The most common pulmonary indications for heart-lung trans-plantation are emphysema (especially a, antitrypsin deficiency), bronchiectasis and cystic fibrosis. Patients with cystic fibrosis represent a large group ofpotential recipients and initial results of heart-lung transplanta-tion in this group are encouraging.' Successful heart-lung transplantation depends on rigorous selection of suitable candidates and, though Address for reprint requests: Mr J Dark, Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NE7 7DN. individual transplant units inevitably have their own criteria, a broad consensus is emerging. The shortage of suitable donors is reflected in the upper age limit of 49 years, and all patients should have respiratory failure unresponsive to conventional medical treatment and a poor quality of life. There should be no appreciable dysfunction of other major organs, particularly the kidneys and liver. This is particularly relevant to patients with cystic fibrosis, who often have liver disease.8 A previous sternotomy or thoracotomy is not …