An international perspective on allocation rules for combined heart-lung transplantation

While the global numbers of lung transplants have increased, the annual numbers of heart-lung transplants have steadily declined over the last decades, combined transplants globally being only about 2% of heart or lung transplant numbers. Although patients eligible for a combined heart-lung transplant may be sicker than those that may be treated with lung transplant only, the increased resource requirement and the dwindling surgical proficiency may have contributed to the declining number of procedures performed. The priority granted to patients requiring a combined transplant in the different organ allocation systems throughout the world vary. In some areas, the candidates for combined transplants compete with urgently ill heart transplant candidates; in others they compete with the lung transplant candidates, and in some there are no defined rules to prioritize those needing a combined heart-lung transplant. The ethical, legal, and practical justifications for the system chosen is often not explicit.