One of the inevitable consequences of success in a new clinical procedure would appear to be a slow but steady relaxation of strict guidelines pertaining to patient selection as familiarity increases. Nowhere has this been more evident than in the field of lung transplantation. After two decades of failure, the early 1980s were characterised by the cautious introduction of heart and lung transplantation for pulmonary vascular disease and single lung transplantation for fibrosing lung disease with clinical success.1

Transplant surgeons and, indeed, their physician colleagues were, however, blessed with a pioneering spirit and were keen to take on new challenges. This manifest itself by the development of a flood of ever increasing indications for lung transplantation. In this respect the decision to perform heart lung transplantation in a patient with respiratory failure due to cystic fibrosis was a milestone. The idea of transplanting an essentially septic recipient with a systemic disease flaunted the received wisdom at the time. Nevertheless, this brave decision has been proved an inspired one with the excellent results obtained offering hope for a new life for many patients with advanced cystic fibrosis.

The two case reports by Licker et al 2 and Hill et al 3 are based on a common theme and illustrate the points above because it is unlikely that either of the patients would have been considered for transplantation in the early 1980s. Results have been successful, at least in the medium term, and the transplant teams are to be congratulated on their success. What conclusions, however, can we draw? In essence both cases revolved around patients whose risk for a successful long term outcome would have to be estimated as less than average at the time the decision to transplant was made. Both cases have been reported as a direct result of success “in adversity” and this success has been used to justify the decision to transplant.

Would the cases have been reported if both patients had died? Lung transplantation has become a victim of it’s own success by failing to deliver an adequate service for well characterised lower risk patients with respiratory failure due to cystic fibrosis, emphysema and pulmonary fibrosis. A shortfall in donor organs has led to most centres experiencing a 50% mortality amongst patients on the active transplant waiting list. Transplant centres must make the best use of a rare resource and, whilst a pioneering spirit must be allowed to flourish, it should not do so if the cost is failure to deliver a service for ever increasing numbers of patients with established indications for whom success is more likely. Perhaps one way forward is for more transplant centres to try to expand the donor lung pool by the use of marginal donors for high risk cases4 and good donor lungs for recipients who represent a lower risk. The introduction of successful lung xenografting in the future remains a tangible but distant prospect.