*Purpose: Combined heart and double-lung transplant (OHT/DLT) is a relatively uncommon procedure, and patient outcomes after undergoing OHT/DLT are therefore not as well understood as heart or lung transplant alone. Our center has performed 40 of these transplants between 2010 and 2021, and we wished to characterize the outcomes of these patients.

*Methods: We performed a retrospective chart review of our patients who have undergone OHT/DLT since our center began performing this surgery in 2010. We divided the patients into two cohorts based on the time of surgery: Cohort I includes the first 20 patients, who were transplanted between 2010 and 2013. Cohort II includes the remaining 20 patients, who were transplanted between 2014 and 2021. Patient demographics, hospital course, and survival status were abstracted from the medical record for our analysis.

*Results: Patients in Phase I performed significantly worse than Phase 2, with 30-day survival of 75% compared to 100% (p < 0.05) and 1-year survival 50% compared to 100% (p < 0.001). Phase I patients were more likely to be discharged with a tracheostomy (53% vs. 15%, p < 0.05), and the most common discharge disposition for Phase I was long-term acute care hospital (67%) while for Phase II it was home (45%). Outside of perioperative deaths, pulmonary graft failure rather than cardiac was almost universally responsible for patient mortality.

*Conclusions: Our outcomes have greatly improved between Cohort I and Cohort II, and in our experience patient mortality was most commonly due to pulmonary complications. We therefore attribute much of this improvement to our monitoring protocol for lung transplant patients. This includes frequent surveillance bronchoscopy, updated immunosuppression and antimicrobial prophylaxis, monitoring for donor-specific antibodies (DSA), and a low threshold to refer patients for anti-reflux surgery (ARS). Previously patients would not be sent for ARS unless they showed signs of declining graft function, but we currently recommend surgery for any signs of silent reflux detected on manometry/impedance. All 6 of the OHT/DLT patients who have undergone ARS are currently living, with a mean time from transplant of 4.3 years. Overall, our outcomes show a significant improvement over time, with a reduction in both perioperative deaths and a current 1-year survival of 100%. We will continue to optimize our treatment protocols for this high-risk and medically vulnerable population.

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