Pulmonary indications for heart-lung transplantation: A modified Delphi survey among the French transplantation...

Heart-lung transplantation (HLTx) is a life-saving intervention for patients with advanced cardiopulmonary disease. Its use has declined significantly in recent decades, and the pulmonary indications for HLTx remain unclear. This study aimed to explore current expert opinions and areas of agreement and disagreement on pulmonary indications for HLTx using a 2-round modified Delphi survey sent to 94 experts at 6 French HLTx centers, including pulmonologists, cardiologists, thoracic surgeons, cardiac surgeons, and anesthesiologists-intensivists. Items relevant to 9 key domains were selected by a working group based on literature reviews. Both surveys had 57 items. Consensus regarding each domain was evaluated by determining the intraclass correlation coefficient (ICC), with an ICC >0.8 indicating strong consensus. In round 1, 40/94 experts responded. The items were scored from 1 to 9: 11 scored >7, 7 scored <3, and 39 had intermediate scores and were reformulated for the second round. The wide interquartile ranges indicated significant variability in responses, and for no domain was the ICC above 0.8. In round 2, which was offered to all experts, the response rate dropped to 25, precluding further statistical analysis. Key areas of disagreement included HLTx indications in severe PAH, right ventricular dysfunction, and congenital heart disease. These findings highlight the absence of a shared consensus and reflect the intrinsic complexity, rarity of the procedure, and variability in institutional expertise. Rather than establishing prescriptive criteria, this expert review underscores the need for individualized, multidisciplinary, and center-specific decision-making, while acknowledging ethical considerations related to donor scarcity. Future efforts should focus on multicenter data collection and predictive models integrating clinical variables and expert judgment to better identify patients who may benefit from HLTx.