**1. Introduction**

Lung transplantation has evolved as the gold standard for select patients with endstage lung disease since the first clinical lung transplant was performed in 1983 in the United States. Over the last few decades, worldwide lung transplantation volume has steadily increased to approximately 4000 cases annually with progressive improvements in long-term survival. Perioperative management of lung transplant recipients is a highly complex endeavor. Crucial components include mechanical ventilation and weaning strategies, fluid management, and immunosuppression including induction therapy, management of rejection, perioperative antibiotics, antimicrobial prophylaxis, chest tube management, nutritional support, discharge planning, and education.

Optimal early outcomes are dependent on a well-coordinated, multidisciplinary approach. Factors that have contributed to improved outcomes include advancements in perioperative critical care, surgical and anesthetic techniques, improved

immunosuppression and understanding of transplant immunobiology, stringent posttransplant surveillance for infection, rejection, and the perioperative use of extracorporeal membrane oxygenation (ECMO) [1] used to bridge decompensating patients to lung transplantation and ex vivo lung perfusion (EVLP) to facilitate optimization and transplantation of marginal donor lungs with outcomes considered equivalent to those from lungs transplanted using standard criteria [2, 3]. Given the aging population, older patients with a higher comorbid burden are being referred for lung transplant evaluation. In the United States, national registry data reveal a progressively increasing number of lung transplant recipients over age 70 years [4]. Advanced CAD is one such comorbidity that is no longer considered an absolute contraindication to lung transplantation. Excellent early outcomes have been reported with concomitant coronary artery bypass grafting (CABG) and lung transplantation [5]. However, the optimal treatment strategy for patients with concomitant advanced CAD and end-stage lung disease remains controversial, requires complex decision-making, and is evolving [6].

Highly sensitized transplant candidates, i.e., those with a high titer of preexisting HLA donor-specific antibodies (DSA), present unique challenges requiring specialized perioperative management. Antibody-mediated rejection (AMR) remains a problem without a reliable treatment in the care of lung transplant patients. AMR is usually mediated by anti-HLA DSA, and both pretransplant and posttransplant DSAs in lung transplant recipients are associated with acute rejection, chronic allograft dysfunction, and decreased survival [7, 8]. Patients transplanted with pretransplant DSAs are at a higher risk of hyperacute/accelerated acute ABMR, chronic rejection, and allograft loss across all solid organs [9]. Although several desensitization protocols have been reported for lung transplant candidates, the guidelines for protocol selection as well as criteria for successful response to treatment remain unclear [10–12].

In this chapter, an overview of general perioperative management of the lung transplant recipient is presented, including specific management strategies for concomitant advanced CAD and end-stage lung disease and perioperative management of the highly sensitized patient are presented.
