Two decades ago, Hans G. Borst initiated the thoracic organ transplant program at the MHH by performing the first heart transplantation. Later, isolated lung and combined heart lung transplantation were added (vide supra). Currently, the MHH represents a major lung transplant center in Europe, as five former coworkers have been appointed program directors in other German LTx-centers within the past 10 years. Until 15th of May 2003, 560 lung transplants were performed, of these 69 combined heart-lung transplantations (Fig. 5).

Meanwhile, the MHH has developed into one of the most active LTx centers worldwide, performing 55 transplants in 2001 and 77 procedures in 2002. Figure 6 depicts the underlying diagnoses. A total of 146 patients were transplanted for pulmonary fibrosis, 128 for pulmonary emphysema and 95 patients with cystic fibrosis. In 46 cases, patients with congenital heart disease underwent HLTx and in 51 cases patients with primary pulmonary hypertension were transplanted. Retransplantation was performed in 42 cases (Fig. 10).

Worldwide, survival rates after LTx show a one-year survival of 70% and a 5-year-survival of about 50% (Fig. 1). In figure 7, the long-term survival in our program is shown. The graph shows, that the survival rates after one as well as after 5 years appear to be significantly better compared to international data. When internally analyzing the MHH results for different surgical approaches, survival curves for the various types of LTx appear to be similar up to 5 years after transplantation. Beyond the 5th postoperative year, however, a significant survival advantage can be seen for patients following DLTx. This observation corroborates world wide data of the ISHLT.

Causes of deaths after HLTx and LTx are different comparing the first year after transplantation and the period beyond (Fig. 2). Early postoperatively, infections and septicemia represent the main causes of death (54%), followed by initial non-function of the graft (14%). BOS accounts for only 6 % in this phase. Beyond the first year, BOS represents the main cause of death (39%), followed by infections (34%). Long-term mortality, therefore, is primarily determined by BOS. Morbidity from BOS, however, is significantly higher (fig. 8).

Five years after transplantation, only 50% of patients are free from BOS, 8 years after transplantation, two thirds of patients are afflicted. Three clinical stages of BOS can be classified, with clinical impairment becoming apparent in stage III (Fig. 9), especially.

In the class II group, BOS can be stabilized by increased immunosuppression in many patients. However. this approach is associated with an increased infectious risk. A further therapeutic option, usually reserved for late stages of the disease, is represented by pulmonary retransplantation for BOS, which has been performed in 26 cases out of a total of 42 re-transplantations so far (Fig. 10).

Comparing survival with first transplantation, re-transplantation for BOS shows a similar survival during the first 5 years. However, re-transplantation after LTx is performed by only few centers, worldwide. The main critique being from the further reduction of available donor organs by increasing cases of re-Tx. Therefore - with respect to the high incidence of BOS in long-term surviving LTx patients and the extreme costs of re-LTx- this procedure does not have the potential to become a readily available treatment option.