Historical perspectives of lung transplantation: connecting the dots

Abstract

Lung transplantation is now a treatment option for many patients with end-stage lung disease. Now 55 years since the first human lung transplant, this is a good time to reflect upon the history of lung transplantation, to recognize major milestones in the field, and to learn from others' unsuccessful transplant experiences. James Hardy was instrumental in developing experimental thoracic transplantation, performing the first human lung transplant in 1963. George Magovern and Adolph Yates carried out the second human lung transplant a few days later. With a combined survival of only 26 days for these first 2 lung transplant recipients, the specialty of lung transplantation clearly had a long way to go. The first "successful" lung transplant, in which the recipient survived for 10.5 months, was reported by Fritz Derom in 1971. Ten years later, Bruce Reitz and colleagues performed the first successful en bloc transplantation of the heart and one lung with a single distal tracheal anastomosis. In 1988, Alexander Patterson performed the first successful double lung transplant. The modern technique of sequential double lung transplantation and anastomosis performed at the mainstem bronchus level was originally described by Henri Metras in 1950, but was not reintroduced into the field until Pasque reported it again in 1990. Since then, lung transplantation has seen landmark changes: evolving immunosuppression regimens, clarifying the definition of primary graft dysfunction (PGD), establishing the lung allocation score (LAS), introducing extracorporeal membrane oxygenation (ECMO) as a bridge to transplant, allowing donation after cardiac death, and implementing ex vivo perfusion, to name a few. This article attempts to connect the historical dots in this field of research, with the hope that our effort helps summarize what has been achieved, and identifies opportunities for future generations of transplant pulmonologists and surgeons alike.

Keywords: Extracorporeal membrane oxygenation (ECMO); history; immunosuppression; lung transplantation; primary graft dysfunction (PGD).

Figure 1

Lord Ganesha, in one of the earliest depictions of xenotransplantation.

Figure 2

Alexis Carrel, a pioneer of early blood vessel anastomosis techniques and solid organ transplantation. Reprinted with permission from the Library of Congress, Prints & Photographs Division, Reproduction Number: LC-DIG-ggbain-34418.

Figure 3

James Hardy, who performed the first human lung transplant. Reprinted with permission from University of Mississippi Medical Center.

Figure 4

The first en bloc heart-lung transplant (left) was carried out at Stanford in 1981 by Bruce Reitz (right) et al. Reprinted with permission from the Stanford School of Medicine Office of Communication & Public Affairs.

Figure 5

Alexander Patterson, who performed the first en bloc double lung transplant. Reprinted with permission from Washington University in St. Louis, Missouri.

Figure 6

Henri Metras, who first described anastomosis at the mainstem bronchus level, which is still used in practice today. Reprinted with permission from Metras D. Henri Metras: a pioneer in lung transplantation. J Heart Lung Transplant, 1992;11(6):1213-5.

Figure 7

Frank Veith, the pioneer of the telescoping anastomosis and the short donor bronchus. Reprinted with permission from NYU Langone Health.

Figure 8

Joel Cooper, who demonstrated that bronchial healing was impaired in patients treated with steroids. Reprinted with permission from Dr. Joel Cooper.

Figure 9

The bronchial anastomosis. Reprinted with permission from Dark JH. Median sternotomy for lung transplantation. Op Tech Thorac Cardiovasc Surg 2015;20:87-103.

Figure 10

The atrial anastomosis. Reprinted with permission from Hayanga JW, D’Cunha J. The surgical technique of bilateral sequential lung transplantation. J Thoracic Dis 2014;6:1063-9.

Figure 11

The clamshell incision, which provides improved pleural space exposure as well as sufficient posterior mediastinal access. Reprinted with permission from Hayanga JW, D’Cunha J. The surgical technique of bilateral sequential lung transplantation. J Thoracic Dis 2014;6:1063-9.

Figure 12

Vaughn Starnes, who carried out the first successful living related lobar transplant. Photograph by Richard Carrasco III, reprinted with permission from Keck School of Medicine at University of Southern California.

Figure 13

Tom Egan, who refined the preclinical foundations of donation after cardiac death. Reprinted with permission from Tom Egan.

Figure 14

Stig Steen, a pioneer in ex vivo lung perfusion. Reprinted with permission from Igelösa Life Science.

Figure 15

The ex vivo lung perfusion circuit. Reprinted with permission from Cypel M, Rubacha M, Yeung J, et al. Normothermic ex vivo perfusion prevents lung injury compared to extended cold preservation for transplantation. Am J Transplant 2009;9:2262-9.

Figure 16

Major milestones in the field of lung transplantation. Reprinted with permission from Norton Thoracic Institute, Phoenix, Arizona.