Heart-lung transplantation—global activity between 2003 and 2023, indications and outcomes

Background: Historically, heart-lung transplantation (HLTx) was the primary treatment for end-stage cardiopulmonary disease. However, advancements in surgery and postoperative care have increasingly enabled the use of bilateral lung transplantation (LTx) instead. This article reviews recent global trends, indications, and outcomes of HLTx. Methods: Global transplant activity was analyzed using data from the European Committee on Organ Transplantation (CD-P-TO). Outcome data were drawn from international registries. Results: From 2003 to 2023, 103 countries reported transplant activity to CD-P-TO, covering a population that grew from 3.22 to 6.07 billion. Between 2019 and 2023, 27 countries reported performing HLTx, with 94 to 108 procedures annually worldwide-equivalent to 0.02 per million population (pmp). In comparison, isolated heart and lung transplants occurred at 1.42-1.75 pmp and 1.05-1.39 pmp, respectively.In Europe, HLTx rates declined from 0.15-0.16 pmp (2003-2008) to 0.04-0.06 pmp (2019-2023). In the U.S., while in the US it slightly increased from 0.08-0.13 pmp to 0.13-0.16 pmp. Pulmonary vascular disease is now the leading indication for HLTx, with recipients averaging 15 years younger than those undergoing isolated thoracic transplants.One-year survival after HLTx is still lower than LTx but slowly increasing. Long-term survival improves in those surviving the first year is better in comparison to isolated LTx. Conclusion: HLTx is currently performed in about one-quarter of reporting countries, accounting for just 1.3%-1.6% of thoracic transplant volume. Despite lower early survival, younger HLTx recipients who survive the initial year show promising long-term outcomes.