Combined Heart–Single-Lung Transplantation: A Unique Operation for Unique Indications John V. Conte, MD, a Rajiv Jhaveri, MD, b Marvin C. Borja, BS, a and Jonathan B. Orens, MD c Combined heart-lung transplantation has been a proven therapeutic option for patients with end-stage cardiopulmonary disease since 1981. Occasional patients are not candidates to receive both lungs en bloc. We describe such a case and propose indications and a surgical technique and present the limited published experience of combined heart-single-lung transplantation. J Heart Lung Transplant 2002;21: 1250 –1253. Combined heart-lung transplantation (HLT) was introduced in 1981 as a treatment of combined cardiopulmonary disease and was the first lung transplantation (LT) procedure to result in long- term human survival. 1 HLT was soon employed for many patients with end-stage lung disease, including those without concomitant cardiac disease. With the introduction of single-lung transplantation (SLT) and later bilateral lung transplantation (BLT), HLT has been reserved for patients with severe end-stage congenital heart disease, with few exceptions, in most transplant centers. 2–5 There remain, however, clinical scenarios in which patients require HLT and do not meet the classic indications for HLT utilizing both lungs or situations in which both lungs are not required or may even be contraindicated. We have successfully performed heart–single- lung transplantation (HSLT) and have listed several other patients for this procedure. Herein we present an illustrative case report, describe the technique utilized, review the published experience with HSLT and discuss the potential applicability of this proce- dure. CASE REPORT The patient was a 51-year-old New York Heart Association (NYHA) Class 4, oxygen-dependent male with a 10-year history of scleroderma. Rele- vant medical history included Raynaud disease with healed digital ulcers and recurrent right-sided pneu- mothoraces treated with mechanical pleurodesis. A computed tomography (CT) scan revealed pulmo- nary fibrosis, cardiomegaly with pulmonary artery dilation, coronary artery calcifications and right pleural thickening. Nuclear scans demonstrated an ejection fraction (EF) of 24% with fixed and revers- ible perfusion defects. Catheterization revealed a right atrial pressure of 15 mm Hg, pulmonary artery pressures (PAP) of 54/22/31 mm Hg, a cardiac output of 3.8 liters and a mixed venous oxygen saturation (MVO 2 ) of 54%. No epicardial coronary artery stenoses were seen and the EF by ventricuog- raphy was 25%. Echocardiograms demonstrated right atrial and ventricular enlargement, septal flat- tening and severe tricuspid regurgitation. Pulmo- nary function tests revealed a forced vital capacity (FVC) of 1.52 liter (30%), forced expiratory volume in 1 second (FEV 1 ) of 1.20 liter (33%), a diffusion capacity (DLCO) of 6.9 cm 3 /m·mm Hg (29%) and an arterial blood gas of 7.52/33/58/26.4 on room air. Examination revealed a jugular venous pulse to the angle of the jaw, ascites and peripheral edema. His cardiac exam demonstrated a regular rhythm with a prominent P2, a loud TR murmur, an S3 gallop and a prominent ventricular heave. The patient was accepted for HSLT because of the previous pleurodesis. The patient was hospital- Departments of a Surgery, b Anesthesia, and c Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland. Submitted October 8, 2001; revised February 8, 2002; accepted March 14, 2002. Reprint requests: John V. Conte, MD, Division of Cardiac Surgery, Blalock 618, Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, Maryland 21287. Telephone: 410-955- 1753. Fax: 410-955-3809. Copyright © 2002 by the International Society for Heart and Lung Transplantation. 1053-2498/02/$–see front matter PII S1053-2498(02)00445-X 1250