Historical background

Success with clinical single lung transplantation was first described by the Toronto group in 1986 [1]. They built on a huge programme of experimental work going back almost 40 years. The basic surgical steps of lung transplantation had been set out by Metras in 1949 [2], much of the physiology being described in a series of experiments coming from the laboratory of Frank Veith in New York. The first human lung transplantation was performed as early as 1963 by Hardy [3]. This case was indeed notable because it demonstrated early function of a lung from a nonheart-beating donor. Other landmarks during the 1970s included an appreciation of the difficulties of ventilation–perfusion (VQ) mismatch in the setting of emphysema [4], and a patient in Belgium who lived for over six months, the latter demonstrating the physiological advantage of giving patients with restrictive disease a transplant [5]. The other theme running through these initial attempts was the problem of bronchial healing [5].

The Toronto group ascribed their success to solution of the bronchus problem (by wrapping with an omental pedicle), and an emphasis on case selection. They realized the advantages of giving a transplant to patients with fibrotic disease and the importance of adequate preoperative rehabilitation.

Evolution of isolated lung transplantation

Fibrotic disease is the ideal indication for a single lung transplant because both ventilation and perfusion are directed towards the graft. The very earliest attempts to perform single lung transplant for emphysema had been unsuccessful because of the preferential ventilation of the much more compliant native lung.