Four decades of heart–lung transplantation: Milestones and outcomes in advanced cardiorespiratory failure

Heart-lung transplantation (HLTx) remains a life-saving intervention for patients with end-stage cardiopulmonary failure. We retrospectively analysed long-term HLTx outcomes at our centre to assess survival trends and evaluate the impact of evolving immunosuppressive, surgical and perioperative strategies. This single-centre retrospective cohort study included 80 patients who underwent HLTx between 1983-1995 (Era 1) and 1996-2010 (Era 2), with follow-up through June 2024. All patients had severe cardiorespiratory failure. The primary endpoint was all-cause mortality. Secondary endpoints included early and late post-transplant outcomes. Overall survival at 1, 5 and 10 years post-transplant was 60 ± 6%, 46 ± 6% and 35 ± 6%, respectively. Survival improved significantly between Era 1 (46 ± 10%, 18 ± 9% and 9 ± 6%) and Era 2 (66 ± 7%, 5 ± 7% and 45 ± 7%) (P < 0.001), correlating with advancements in immunosuppression, organ preservation and perioperative care. Univariable risk factors for increased mortality included Euro Collins versus Perfadex lung preservation (P < 0.001), University of Wisconsin (UW2) versus Histidine-Tryptophan-Ketoglutarate (HTK) solution cardioplegia (P < 0.001), and Epstein-Barr virus infection (P = 0.036). Heart failure: OR 4.557 (95% CI: 1.057-19.648, P = 0.042) and gastrointestinal bleeding: OR 2.739 (95% CI: 1.310-5.726, P = 0.016) were identified as risks for mortality. These factors remained significant in multivariable analysis. HLTx outcomes at our centre are consistent with international benchmarks. Survival has improved in Era 2, likely due to individualised immunosuppressive regimens, novel organ preservation techniques and enhanced surveillance. These results support ongoing optimisation of multidisciplinary care for complex cardiopulmonary failure.