Lung Transplant in India and UAE | Complete Patient Guide

• ELIGIBLE CONDITIONS: End-stage COPD/emphysema (FEV1 < 20% predicted with homogeneous distribution or DLCO < 20%), idiopathic pulmonary fibrosis (FVC < 80% or DLCO < 40% with 10% decline over 6 months), cystic fibrosis (FEV1 < 30% predicted), pulmonary arterial hypertension refractory to prostacyclin therapy, bronchiectasis, sarcoidosis, lymphangioleiomyomatosis (LAM), and re-transplantation for chronic lung allograft dysfunction (CLAD/BOS).

• FUNCTIONAL ELIGIBILITY CRITERIA: NYHA/WHO functional class III–IV; resting or exertional oxygen dependence; significant functional limitation despite maximal medical therapy; estimated 2-year mortality > 50% without transplant (assessed using disease-specific risk scores such as the BODE index for COPD or the GAP model for IPF).

• REQUIRED DIAGNOSTIC WORKUP (PRE-TRANSPLANT EVALUATION): High-resolution CT (HRCT) chest, full pulmonary function tests (spirometry, body plethysmography, DLCO), 6-minute walk test (6MWT), right heart catheterization, transthoracic echocardiography (TTE/ECHO) with Doppler, coronary angiography (patients > 40 years or with cardiac risk factors), V/Q scintigraphy, arterial blood gas (ABG) analysis, complete metabolic panel, renal and hepatic function tests, HLA typing and crossmatch, CMV/EBV/HIV/HBV/HCV serology, bone density scan (DEXA), and psychosocial assessment.

• ABSOLUTE CONTRAINDICATIONS: Active malignancy within the past 2 years (excluding non-melanoma skin cancers), severe non-pulmonary organ dysfunction (renal GFR < 40 mL/min, hepatic cirrhosis, significant coronary artery disease not amenable to revascularization), active extrapulmonary infection including tuberculosis, documented non-adherence to medical regimens, active tobacco/substance use within 6 months, and uncontrolled psychiatric illness.

• RELATIVE CONTRAINDICATIONS: Age > 65 years (SLT) or > 60 years (BSLT) is not absolute but increases risk stratification; severe osteoporosis; BMI > 35 or < 17 kg/m²; mechanical ventilation or ECMO dependency prior to listing increases urgency and risk; prior pleurodesis or thoracic surgeries (increases technical complexity).

BILATERAL SEQUENTIAL LUNG TRANSPLANT (BSLT — GOLD STANDARD): The preferred technique for most diagnoses including COPD, CF, and PAH. The recipient undergoes sequential replacement of each lung through a clamshell (bilateral anterolateral thoracotomy) or bilateral thoracosternotomy incision. Each bronchial, pulmonary artery, and pulmonary vein anastomosis is completed individually. ECMO (venoarterial or venovenous) is the preferred circulatory support modality over traditional cardiopulmonary bypass, as it is associated with lower rates of primary graft dysfunction (PGD) and improved coagulation profiles. BSLT yields superior long-term survival and is now performed in over 75% of all lung transplants globally.

SINGLE-LUNG TRANSPLANT (SLT): Indicated primarily for IPF and selected COPD patients. Performed via a standard posterolateral thoracotomy. SLT carries shorter operative time and reduced donor organ demand but is associated with greater ventilation-perfusion mismatch and lower long-term survival compared to BSLT. The technique is less suitable for septic lung diseases (CF, bronchiectasis) where the native lung could contaminate the allograft.

HEART-LUNG TRANSPLANT (HLT): Reserved for Eisenmenger syndrome, end-stage PAH with biventricular failure, and complex congenital heart disease with pulmonary hypertension. Requires total cardiopulmonary bypass and en-bloc implantation of the donor heart and lungs. Performed at select high-volume centers in India (Chennai, Mumbai) and the UAE (Cleveland Clinic Abu Dhabi).

EX VIVO LUNG PERFUSION (EVLP): A groundbreaking organ reconditioning technology (Vivoline LS1 or XVIVO Perfusion System) that allows surgeons to assess and repair marginal or declined donor lungs outside the body using a normothermic perfusion circuit. EVLP can expand the usable donor pool by 20–30% and is now offered at advanced transplant programs in India and the UAE, significantly reducing waitlist mortality.

INTRAOPERATIVE ECMO: Modern transplant programs have shifted from conventional CPB to ECMO (Maquet Cardiohelp, LivaNova) for circulatory support during transplantation. ECMO offers superior lung protection, fewer systemic inflammatory responses, reduced blood product utilization, and the ability to transition seamlessly to post-operative support if primary graft dysfunction occurs.

IMMUNOSUPPRESSION PROTOCOLS: Modern triple-drug maintenance regimens include tacrolimus (target trough 10–15 ng/mL in the first year), mycophenolate mofetil (MMF) 1,000–1,500 mg twice daily, and prednisolone with planned tapering. Induction agents such as basiliximab (IL-2 receptor antagonist) or anti-thymocyte globulin (ATG) are used perioperatively to reduce early rejection risk. mTOR inhibitors (sirolimus, everolimus) may replace CNIs in select patients for renal preservation or management of chronic lung allograft dysfunction (CLAD).

ACUTE REJECTION MANAGEMENT: Acute cellular rejection (ACR) is classified per ISHLT grading (A0–A4) on transbronchial biopsy. Grade A2 and above is treated with high-dose IV methylprednisolone (500–1,000 mg × 3 days). Antibody-mediated rejection (AMR) is managed with plasmapheresis, IV immunoglobulin (IVIG), and rituximab. Chronic lung allograft dysfunction (CLAD), including bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS), remains the leading cause of late mortality and is managed with azithromycin, montelukast, extracorporeal photopheresis (ECP), and where appropriate, re-transplantation.

PHASE 1 — REMOTE PRE-EVALUATION (WEEKS 1–3): GAF Healthcare coordinates the transfer of all prior medical records, imaging (HRCT, PFTs, ECHO, right heart catheterization), and laboratory results to the chosen transplant center. The transplant pulmonologist and cardiothoracic surgeon conduct a telemedicine consultation to determine candidacy and provisional listing status. A detailed cost estimate and logistical plan are provided.

PHASE 2 — IN-COUNTRY PRE-TRANSPLANT EVALUATION (DAYS 1–7 AFTER ARRIVAL): Upon arrival, the patient undergoes a comprehensive in-person evaluation including repeat pulmonary function testing, 6-minute walk test, echocardiography, coronary angiography (if indicated), HLA typing and donor-specific antibody (DSA) panel-reactive antibody (PRA) testing, CT chest with contrast, and full metabolic and infectious disease screening. The multidisciplinary transplant committee convenes to confirm listing and assign waitlist status per NOTTO (India) or MoHAP/DHA (UAE) protocols.

PHASE 3 — WAITING PERIOD & DONOR MATCHING: Waiting time varies significantly and is unpredictable, ranging from days to several months. GAF Healthcare arranges suitable local accommodation for the patient and attendant. The transplant team maintains the patient in optimal medical condition through pulmonary rehabilitation, optimization of nutritional status, and management of comorbidities. Patients may be bridged with supplemental oxygen, non-invasive ventilation (NIV/BiPAP), or in urgent cases, ECMO as a bridge to transplant (BTT).

PHASE 4 — TRANSPLANT SURGERY (OPERATIVE DAY): Upon donor organ availability and confirmation of acceptable cold ischemic time (ideally < 6 hours for bilateral lungs), the patient is admitted urgently and prepared for surgery. The operative procedure (BSLT, SLT, or HLT) typically takes 6–12 hours under general anesthesia with intraoperative ECMO or CPB support. The surgical team performs bronchial, pulmonary artery, and pulmonary vein (or left atrial cuff) anastomoses under meticulous tension-free technique. Bronchial anastomotic integrity is assessed with intraoperative bronchoscopy.

PHASE 5 — ICU & ACUTE POST-OPERATIVE CARE (DAYS 1–14): The patient is managed in the cardiothoracic ICU with mechanical ventilation (targeted to early extubation within 24–48 hours where possible), continuous hemodynamic monitoring, ECMO weaning protocols, immunosuppression initiation, anti-infective prophylaxis (trimethoprim-sulfamethoxazole for PCP, valganciclovir for CMV, fluconazole/voriconazole for fungal prophylaxis), and daily surveillance bronchoscopies with BAL cultures. Primary graft dysfunction (PGD) is graded per ISHLT criteria and managed with lung-protective ventilation, prone positioning, and ECMO if grade PGD 3.

PHASE 6 — STEP-DOWN WARD & REHABILITATION (DAYS 14–40): Transition from ICU to a specialized thoracic step-down unit. Progressive chest physiotherapy, incentive spirometry, and supervised pulmonary rehabilitation commence. Surveillance transbronchial biopsies are performed at weeks 3, 6, and 12 post-transplant to detect subclinical rejection. Tacrolimus and MMF dosing is optimized based on trough levels and renal function. Discharge planning begins, with patient and caregiver education on home spirometry monitoring (FEV1/FVC diary), medication schedules, and rejection/infection symptom recognition.

PHASE 7 — POST-DISCHARGE OUTPATIENT FOLLOW-UP (WEEKS 6–16): Weekly outpatient clinic visits at the transplant center for the first 6–8 weeks post-discharge, covering pulmonary function monitoring, drug level testing, chest X-rays, and bronchoscopy as indicated. The fit-to-fly assessment incorporates: stable or improving FEV1 (> 50% predicted), no active rejection or infection, oxygen independence at rest and with ambulation, and physician sign-off on fitness for long-haul travel (minimum 10–16 weeks post-transplant for intercontinental flights). GAF Healthcare coordinates all follow-up appointments and the transition to the patient's home country pulmonologist with a full medical handover package.