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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 4  |  Issue : 2  |  Page : 88-95

Lung transplant: The Indian experience and suggested guidelines – Part 1 selection of the donor and recipient


1 Department of Heart and Lung Transplantation, Apollo Hospitals, Chennai, Tamil Nadu, India
2 Departments of Cardiothoracic Surgery, AIIMS, New Delhi, India
3 Departments of Cardiology, AIIMS, New Delhi, India

Date of Web Publication10-Sep-2018

Correspondence Address:
Dr. T Sunder
Department of Heart and Lung Transplantation, Apollo Hospitals, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_46_18

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  Abstract 

Background: The selection of the correct donor lung is crucial for a successful lung transplant. Since the median survival after lung transplant is 5 years and the morbidity and mortality of lung transplant is higher than other transplants, it is crucial to preselect the correct recipient. Methodology: In India, Dr. P. Venugopal at the All India Institute of Medical Sciences, New Delhi, performed the first successful heart transplant, while Dr. K. M. Cherian performed the first heart–lung transplant at Chennai. At Apollo Hopsitals, Chennai, the first heart transplant was performed by Dr. M. R. Girinath. Subsequently, the Department of Heart and Lung Transplantation at Apollo Hospitals, Chennai, have performed a large number of heart and lung transplants and its experience is summarized. Results: The Department of Heart and Lung Transplantation at Apollo Hospitals, Chennai, has done 101 lung and 62 heart transplants as part of their lung and heart lung transplant program. There were 21 heart–lung transplants and 25 double lung transplants. The results are discussed and indications, contraindications for lung and heart–lung transplant as well as recipient and donor workup are discussed in this first part of a set of three articles. Conclusions: Careful selection of a recipient and donor leads to a successful lung and heart–lung transplant program.

Keywords: Extracorporeal membrane oxygenation (ECMO), lung transplantation, timing of surgery, transplant window


How to cite this article:
Sunder T, Ramesh T P, Kumar K M, Suresh M, Singh SP, Seth S. Lung transplant: The Indian experience and suggested guidelines – Part 1 selection of the donor and recipient. J Pract Cardiovasc Sci 2018;4:88-95

How to cite this URL:
Sunder T, Ramesh T P, Kumar K M, Suresh M, Singh SP, Seth S. Lung transplant: The Indian experience and suggested guidelines – Part 1 selection of the donor and recipient. J Pract Cardiovasc Sci [serial online] 2018 [cited 2018 Dec 12];4:88-95. Available from: http://www.j-pcs.org/text.asp?2018/4/2/88/240968


  Introduction Top


Lung transplantation in humans was first attempted almost 55 years ago by James Hardy in 1963.[1] There were a lot of problems in the initial decades because of rejection and anastomotic site healing. Rejection rates improved with the introduction of cyclosporin. Improved surgical techniques were also devised.

There were no long-term survivors for two decades. About 44 patients worldwide underwent lung transplant with no long-term survivors.[2] It was only in 1983 that Joel Cooper reported the first successful single lung transplant in humans.[3] Gradually, with better surgical techniques and better understanding of the lung transplant physiology and immunology, the results improved and now the survival is 80% at 1 year, 65% at 3 years, and 54% at 5 years [Figure 1].
Figure 1: Survival after lung transplant.

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In India, the first successful heart transplant was performed at All India Institute of Medical Sciences by Dr. P. Venugopal [Figure 2] in 1994.[4] The first successful heart–lung transplant in India was performed by Dr. KM Cherian [Figure 3] at Chennai.[5] At Apollo Hospitals, Chennai, the first heart transplant was performed by Dr. M. R. Girinath [Figure 4] in 1995. At that time, there was no formal transplant program and sporadic cases were performed in the next 2 years with varying results and subsequently, no further heart transplants were done. A formal Cardiothoracic Transplant program at Apollo Hospitals, Chennai, was envisioned by the transplant team of Dr. Paul Ramesh and Dr. T. Sunder, cardiothoracic surgeons and their first step was to develop a multidisciplinary team of specialists who were passionate about transplant and the department was built and protocols developed – largely from the Papworth Hospitals in the UK. The transplant program was largely a surgeon-led program. The first heart transplant successfully done by this group was in 2006. Over the years, problems specific to the Indian scenario were encountered and protocols were tailored to meet Indian conditions.
Figure 2: Dr. P.Venugopal who performed first heart transplant in India.

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Figure 3: Dr. K. M. Cherian who did the first heart–lung transplant in India.

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Figure 4: Dr M. R.Girinath who did the first heart transplant at Apollo Hospitals, Chennai.

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The first heart–lung transplant at Apollo Hospitals, Chennai, and second in India was performed by Dr. Paul Ramesh and Dr. T. Sunder in 2007. With the experience gained in dealing with heart transplants in Indian patients, both recipients and donors, the team commenced the lung transplant program. In 2011, the transplant team grew with addition of Dr. Madhan Kumar – also a cardiothoracic surgeon. In 2016, Dr. Suresh Manickavel, transplant physician and pulmonologist joined the Apollo Heart and Lung Transplant team [Figure 5]. At Apollo Hospitals, Chennai, the first isolated lung transplant was performed in 2011 by Dr. Paul Ramesh, Dr. Madhan Kumar, and Dr. T. Sunder, which was a single lung transplant. The unit has then progressed to performing double lung transplants and preferentially performs double lung transplants whenever possible.
Figure 5: (L to R) Dr. M. Suresh, Dr. T. Sunder, Dr. K. Madhan Kumar, Dr. T. Paul Ramesh.

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The current transplant team comprises of dedicated multidisciplinary team of transplant surgeons, transplant physicians, cardiologists, pulmonologists, anesthetists, intensivists, perfusionists, nephrologists, gastroenterologists, immunologists, radiologists, pathologists, gynecologists, neurologists, psychologists, transplant coordinators, and nurses.

Live-related Kidney transplants were performed since 1983 when the Hospital started functioning under the stewardship of Dr. Mani. After the passing of the Transplantation of Human Organs Act in 1994, cadaveric-deceased donor kidney transplants are being regularly done.

Some of the problems faced by the lung transplant units in India[5] include late referral, reluctance of physicians to refer cases due to lack of confidence in surgical outcomes, bed bound and sick patients who have developed myopathies and are therefore not very good surgical patients, ventilator dependence of patients, ventilator-associated pneumonia and graft dehiscence, and tubercular infection both in the recipient and the donor.

Selection of the lung for lung transplant and the correct recipient is crucial for a successful lung transplant. The indications for lung transplant have been detailed by the pulmonary transplantation council of the International Society for Heart and Lung Transplant 2014. Referral for lung transplant should occur early in end-stage lung disease, but the guidelines for India need to be evolved with experience and time. This document will try to document the experience of one hospital as a model and then try to document the experiences of other hospitals similarly to evolve a consensus.


  Methodology Top


The AIIMS and Apollo Hospital Chennai are organizing a series of 3 hands on workshops on heart–lung transplant [Figure 6]. The proceedings will be published in this journal and will act as a starting point for hospitals who want to start their own transplant programs.
Figure 6: Participants of the lung transplant workshop at AIIMS, New Delhi.

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The selection process for the donor and recipient is highlighted in this document and the Indian experience for each component is expanded by the Apollo experience.


  Results Top


The Heart and Lung Transplant Team, Apollo Hospitals, Chennai, has assessed a total of about 154 patients and transplanted 163 organs in 94 patients. This includes 101 lungs and 62 hearts. There were 39 heart transplants with three bridge to transplants where two were bridged from a ventricular-assist device and one from an extracorporeal membrane oxygenator. There were 21 combined heart and lung transplants. There was one combined heart–lung and kidney transplant. There was one combined heart and liver transplant, which was an en bloc heart–liver transplant, the first of its kind in Asia. There were 25 double lung transplants including one bridged from an extracorporeal membrane oxygenator. There were seven single lung transplants including one being bridged from a ventilator. Postsurgery, 89.3% of the heart transplant patients were doing well and 73% of the lung transplant patients were doing well (80% survival in primary pulmonary hypertension and 67% survival in interstitial lung disease [ILD]) [Figure 7] and [Figure 8].
Figure 7: The Apollo Heart and lung transplant team with 4 long-term survivors after combined heart–lung transplant.

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Figure 8: Apollo Heart and Lung Transplant Team with the oldest recipient of heart-lung transplant in India after an uneventful laparoscopic cholecystectomy 4 years post transplant under general anaesthesia

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  Discussion Top


Heart–lung and lung transplant in India is in its infancy with limited centers doing the procedure. We have presented the experience of the Department of Heart and Lung Transplantation, Apollo Hospitals, Chennai, which has one among the largest numbers of lung transplants in India and has discussed the selection process for the recipient and the donor.

Recipient aspects

Indications for lung transplant

This section deals with indications for lung transplant,[6],[7] both general aspects and objective criteria that need to be met in different groups of lung disease (disease-specific indications).

General indications

The general indication for lung transplant [Table 1] is chronic end-stage lung disease with:
Table 1: General indications for lung transplant

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  • <50% chance of surviving 2 years without lung transplant
  • >80% chance of surviving 90 days after transplant
  • >80% chance of surviving 5 years from a medical perspective, provided the graft (transplanted lung) function is adequate.


Disease-specific indications

These include specific objective criteria, in different lung diseases, which need to be present in order to consider lung transplantation.[8]

Interstitial lung disease

Patients are referred when there is interstitial pneumonitis or fibrosing nonspecific interstitial pneumonitis[8] with forced vital capacity <80% predicted, diffusing capacity of the lung for carbon monoxide <40% predicted, and desaturation to <88% on room air [Table 2].
Table 2: Indications for lung transplant in interstitial lung disease

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Chronic obstructive pulmonary disease

Patients with chronic obstructive pulmonary disease (COPD) are referred for lung transplant[8] when the disease is progressive despite maximal therapy with PaCO2 >50 mmHg, PaO2 <60 mmHg, and forced expiratory volume in 1 s (FEV1) <25% predicted [Table 3]. The BODE Index[9] is an objective scoring system which takes into account the body mass index (BMI), degree of airflow obstruction FEV1, degree of dyspnea and exercise capacity measured by 6-min walk distance. Each of the parameter has a numerical value and the sum total gives BODE Index [Table 4].
Table 3: Indications for lung transplantation in chronic obstructive pulmonary disease

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Table 4: The body mass index, degree of airflow obstruction and dyspnea, and exercise capacity index consists of the following

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Idiopathic pulmonary artery hypertension

Treatment for pulmonary artery hypertension is largely medical with pulmonary vasodilators and transplantation is only indicated[8] when there is clinical deterioration in spite of maximal medical therapy [Table 5].
Table 5: Indications for lung transplant in idiopathic pulmonary artery hypertension

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Cystic fibrosis

These patients are referred for assessment when the FEV1 has fallen to 30%, decline in the 6-min walk[8] distance and worsening clinical condition, despite maximal medical therapy [Table 6].
Table 6: Indications for lung transplant in cystis fibrosis

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Contraindications for lung transplant

These conditions may preclude a transplant operation, and thus it is important that these conditions are looked for and treated before any decision to transplant.[6],[7],[10]

Absolute contraindications

The absolute contraindications which preclude lung transplantation are discussed below [Table 7]. Every effort must be taken to ensure that these absolute contraindications are ruled out prior to listing for lung transplantation.
Table 7: Absolute contraindications for lung transplantation

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Malignancy: Active current malignancy is an absolute contraindication. In patients with treated malignancies in the past, the treatment must be deemed to have been curative with a disease-free period of 5 years, though in some malignancies a 2-year disease period is adequate.

Untreatable organ dysfunction (heart, liver, kidney, and brain) – unless a combined transplant is being considered.

  • Bleeding diathesis
  • Untreatable atherosclerotic disease
  • Acute medical problems such as sepsis, myocardial infarction, and liver failure
  • Chronic virulent uncontrollable infection
  • Active tubercular infection
  • Significant chest or spinal deformity
  • Significant obesity (BMI >35 kg/m2)
  • Current nonadherence to medications
  • Psychiatric issues
  • No good support system
  • Substance abuse.


Relative contraindications

The relative contraindications to lung transplantation [Table 8] include medical conditions, each of which needs to be considered on individual merit.[6],[7]
Table 8: Relative contraindications to lung transplantation

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  • Age >65 years
  • BMI: 30–34 kg/m2
  • Severe malnutrition
  • Severe osteoporosis
  • Previous chest surgery
  • Mechanical ventilation (MV) or extracorporeal lung support
  • Colonisation with virulent organisms
  • Hepatitis B/C – only if stable on treatment with no sequelae
  • HIV – only if stable and HIV – RNA is undetectable
  • Diabetes with end-organ damage.


Pretransplant recipient workup

Pulmonary

  • Pulmonary function tests including spirometry, lung volumes, diffusing capacity, and arterial blood gases
  • 6-min walk test
  • Chest X-ray
  • Computed tomogram of chest, head, and brain
  • Fiberoptic bronchoscopy
  • Quantitative V/Q scan, especially when single lung transplant is being contemplated to assess which lung is more affected functionally.


Cardiac

  • Electrocardiogram
  • Echocardiogram with assessment of the right heart function
  • Right and left heart catheterization
  • Dobutamine/thallium Stress test may be considered if cardiac catheterization is not done.


Gastroesophageal

It is important to rule out gastroesophageal reflux disease (GERD). Upper graphical interface endoscopy, pH monitoring, oesophageal manometry, and impedance manometry are needed.

Hepatic assessment

Synthetic function of liver and presence or absence of fibrosis in liver need to be assessed.

Infection

  • Mantoux test
  • Serologies for Cytomegalovirus immunoglobulin G (IgG) and IgM, varicella zoster Virus IgG and IgM, Epstein–Barr Virus IgG and IgM, measles, HIV antibodies, HBsAg, hepatitis B antibody, and hepatitis C Virus antibody
  • Toxoplasma titers
  • Vaccinations
  • Pneumovax
  • Annual influenza vaccine
  • Hepatitis B if not immune
  • Varicella if not immune
  • Tetanus every 10 years
  • Sputum culture and sensitivity test, fungi, and acid–fast bacillus in bronchiectasis and cystic fibrosis.


Laboratories

  • Complete blood count
  • Liver function biochemical tests
  • Renal function biochemical tests – urea, creatinine, and electrolytes
  • Coagulation profile
  • Lipid profile
  • Fasting, postprandial sugars, and Hba1c
  • Thyroid function tests
  • Cortisol levels
  • Follicle-stimulating hormone and luteinizing hormone in female patients
  • Prostate-specific antigen and testosterone levels in male patients
  • Vasculitis screen in patients with suspicion of autoimmune disease or connective tissue disease.


Miscellaneous tests

  • Blood group – checked twice
  • Human leukocyte antigen tissue typing
  • Panel reactive antibody (PRA) screen
  • Pap smear and mammograms in all female patients every year
  • Urine analysis, 24-h creatinine clearance
  • Duplex scan to rule out deep vein thrombosis
  • Arterial Doppler of the lower limbs in case of suspicion of peripheral vascular disease
  • Carotid Doppler in patients with suspected vascular disease
  • Bone densitometry for patients with a history of steroid therapy
  • Dental clearance
  • ENT clearance, especially in patients with cystic fibrosis
  • Nephrology clearance
  • Evaluation by psychiatrist and social worker.


Donor aspects

Donor selection is crucial, and it is pertinent to note that, among the donor pool only about 17%–20% of the lungs are usable as opposed to much higher rates of usable organs such as kidney, liver, and heart. The ideal donor should have characteristics as listed below [Table 9].
Table 9: Characteristics of ideal lung donor

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Characteristics of an ideal donor

  • ABO compatible donor
  • Size match using height and predicted total lung capacity
  • Age <55 years
  • Smoking history of <20 pack years
  • No chest trauma
  • Ventilated lass than 72 h with PaO2 >300 mmHg on 100% oxygen and 5 cm of positive end-expiratory pressure
  • Normal bronchoscopy with minimal or no secretions and no organisms on Gram stain from bronchial lavage
  • No evidence of aspiration or sepsis
  • No prior thoracic surgery on the side of harvest.


Transplant decision

This section discusses the decision-making process involved in recommending lung transplant to patients.[5]

Whether transplant is appropriate?

The following three questions need to be considered by the physician/transplant team and only if the answer to each of these questions is “yes,” should a transplant be recommended.

  • Q.1. Has the disease reached end stage? (Disease point of view)
  • Q.2. Can the patient tolerate the operation? (Patient point of view)
  • Q.3. Have all contraindications been ruled out?


Disease point of view

It is crucial that all nontransplant treatment options are tried/considered and found to be futile before decision to transplant.

Patient point of view

The comprehensive assessment by the multidisciplinary team of specialists is important in evaluating each organ system and more importantly in ensuring that there are no absolute contraindications for transplant.

Timing of transplant

The correct timing of transplant operation is a crucial factor which has a significant impact on outcomes.

Transplant window

It is the ideal time period to consider the operation, wherein the lung has reached end stage, but all the other organ systems are well preserved. Such patients do well.

Too well for transplant

Considering transplant in a patient early on in the disease process, that is, before end-stage disease is hazardous. This is because the risks to the patient from the transplant operation would be higher than the risk to the patient from the lung disease.

Too sick for transplant

On the other hand, considering transplant in a patient who has advanced disease with multiorgan failure is inappropriate. This is because the outcomes in the subgroup are often fatal. Furthermore, donor organs are a scarce resource and should be used appropriately.

Decision-making process

Two main risk assessment processes help in decision to register a patient for transplant.

Risk–benefit analysis of transplant operation

If the anticipated are much higher than the possible risks, decision to consider transplant is made. Conversely, if the risks are prohibitive in the face of very little benefit, the patient is strongly dissuaded from having a transplant.

Risks with transplant versus risks without transplant

This is another important consideration which helps in decision-making. If the risks from the disease, without transplant, is much higher than the risks involved in transplant operation, decision to consider transplant is made.

Bridging to lung transplant

When patients, who are on the waitlist for transplant, suddenly deteriorate resulting in MV or institution of extracorporeal membrane oxygenation (ECMO), they may be considered for lung transplant.

Thus, MV and ECMO may be used to “bridge”-selected patients to successful lung transplant.[11],[12],[13],[14],[15],[16] Among our lung transplant patients, we have bridged one patient from ECMO and one patient from MV. The outcome of lung transplant in patients who are bridged from MV or ECMO are acceptable, provided they are stable on MV or ECMO, before transplant.

Situations specific to the India

Late presentation of patients

We have observed quite uniformly that our patients, unlike in the West, present very late in the course of the disease.[5],[17] This is attributable to two factors – Patient factors and physician factors.

Patient factors

By and large Indian patients often dread surgery and end up putting off their decision, until it is too late. In some instances, religious beliefs regarding organ transplantation may deter acceptance to transplant operation even when they are “fit” for a transplant. The inevitable clinical deterioration “forces” them to agree eventually, by which time they are bed bound with muscle wasting and result in stormy postoperative courses and lesser surgical outcomes.

Physician factors

Initial reluctance of physicians to refer patients for transplant may be due to decreased awareness of availability of such a treatment option in India and the suboptimal surgical outcomes in patients who presented late. Our increasing experience and standardizing protocols with improved results has, to an extent, overcome the reluctance and we now are seeing increasing referrals at appropriate time.

Endemicity of tuberculosis

Tuberculosis (TB) is endemic in India and this impacts on both recipients and donors.[5]

In recipients: Special emphasis is to made during pretransplant workup to rule out TB. We have, on one occasion, done mediastinoscopy under high-risk general anesthesia to sample mediastinal nodes and commenced antituberculous therapy after a positive histology report. It is important to diagnose TB and treat appropriately before listing for transplant, in view of postoperative immunosuppression.

In donors: Subclinical TB needs to be excluded in donors before organ retrieval. While the presence of normal chest X-ray with normal bronchoscopy rules out parenchymal pulmonary TB, mediastinal tuberculous lymphadenopathy is quite prevalent in India may be missed. Perhaps, in our country, computed tomography scan of the chest needs to be considered, wherever feasible, as a part of evaluation of donor mediastinum.

Some characteristics of favorable recipient (for the first case when starting a program) based on Indian experience

  • Age <60 years
  • Able to walk with oxygen supplement for at least 250 m with or without rest in 6 min
  • Patients referred appropriately with no evidence of frailty, myopathy, or muscle weakness.
  • PRA levels <5%
  • Steroid dose less than or equivalent to Prednisone 10 mg/day
  • Preferably no or mild GERD
  • Adequate right ventricular function (Tricuspid Annular Plane Systolic Excursion – [TAPSE] >12 mm) in the setting of pulmonary artery hypertension
  • No renal or hepatic impairment
  • Diabetes – if present, to be well controlled with no end-organ damage
  • Recipient with COPD would be an ideal first case from the surgical point of view compared to ILD
  • Single lung transplant has good early results, but lesser long-term survival
  • Double lung transplant has a difficult early period, but better long-term survival.



  Conclusions Top


For a successful lung or heart–lung transplant, we need to choose carefully the correct recipient, the correct donor, have the transplant team in place and go ahead and be prepared for all the complication which can occur. This would result in patients surviving more than 1 year and reaching a median survival equal to Western figures of 50% at 5 years.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Hardy JD, Webb WR, Dalton ML Jr., Walker GR Jr., Lung homotransplantation in man. JAMA 1963;186:1065-74.  Back to cited text no. 1
    
2.
Kotloff RM, Thabut G. Lung transplantation. Am J Respir Crit Care Med 2011;184:159-71.  Back to cited text no. 2
    
3.
Toronto Lung Transplant Group. Unilateral lung transplantation for pulmonary fibrosis. N Engl J Med 1986;314:1140-5.  Back to cited text no. 3
    
4.
Venugopal P. The first successful heart transplant in India. Natl Med J India 1994;7:213-5.  Back to cited text no. 4
    
5.
Sunder T, Paul Ramesh T, Madhan Kumar K. Heart & Heart Lung Transplantation: Indian Scenario. In: Guha S, editor. Cardiology Update 2015. 1st ed. New Delhi: Jaypee Brothers; 2016. p. 1460-4.  Back to cited text no. 5
    
6.
Orens JB, Estenne M, Arcasoy S, Conte JV, Corris P, Egan JJ, et al. International guidelines for the selection of lung transplant candidates: 2006 update – A consensus report from the pulmonary scientific council of the international society for heart and lung transplantation. J Heart Lung Transplant 2006;25:745-55.  Back to cited text no. 6
    
7.
Weill D, Benden C, Corris PA, Dark JH, Davis RD, Keshavjee S, et al. A consensus document for the selection of lung transplant candidates: 2014 – An update from the pulmonary transplantation council of the international society for heart and lung transplantation. J Heart Lung Transplant 2015;34:1-5.  Back to cited text no. 7
    
8.
Nathan SD. Lung transplantation: Disease-specific considerations for referral. Chest 2005;127:1006-16.  Back to cited text no. 8
    
9.
Celli BR, Cote CG, Marin JM, Casanova C, Montes de Oca M, Mendez RA, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med 2004;350:1005-12.  Back to cited text no. 9
    
10.
Kreider M, Hadjiliadis D, Kotloff RM. Candidate selection, timing of listing, and choice of procedure for lung transplantation. Clin Chest Med 2011;32:199-211.  Back to cited text no. 10
    
11.
Baz MA, Palmer SM, Staples ED, Greer DG, Tapson VF, Davis DD, et al. Lung transplantation after long-term mechanical ventilation: Results and 1-year follow-up. Chest 2001;119:224-7.  Back to cited text no. 11
    
12.
Meyers BF, Lynch JP, Battafarano RJ, Guthrie TJ, Trulock EP, Cooper JD, et al. Lung transplantation is warranted for stable, ventilator-dependent recipients. Ann Thorac Surg 2000;70:1675-8.  Back to cited text no. 12
    
13.
Dellgren G, Riise GC, Swärd K, Gilljam M, Rexius H, Liden H, et al. Extracorporeal membrane oxygenation as a bridge to lung transplantation: A long-term study. Eur J Cardiothorac Surg 2015;47:95-100.  Back to cited text no. 13
    
14.
Chiumello D, Coppola S, Froio S, Colombo A, Del Sorbo L. Extracorporeal life support as bridge to lung transplantation: A systematic review. Crit Care 2015;19:19.  Back to cited text no. 14
    
15.
Lin J. Extracorporeal membrane oxygenation support bridge to transplant: Avoiding a bridge to nowhere. J Thorac Cardiovasc Surg 2017;154:1796-7.  Back to cited text no. 15
    
16.
Kinaschuk K, Bozso SJ, Halloran K, Kapasi A, Jackson K, Nagendran J, et al. Mechanical circulatory support as a bridge to lung transplantation: A single Canadian institution review. Can Respir J 2017;2017:5947978.  Back to cited text no. 16
    
17.
Girinath MR, Paul Ramesh T, Sunder T. Cardiac transplantation. In: Khalilullah M, editor. Cardiology. 1st ed. New Delhi: The Heart Centre; 2012. p. 392-6.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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