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domino procedure. Methods: An electronic search was performed to identify all studies on the domino procedure in the English literature. Eight studies reporting on a total of 183 HLT recipients and 266 HT recipients were included for final analysis. Results: HLT indications included cystic fibrosis in 58% (95%CI: 27-84) of recipients, primary pulmonary hypertension in 17% (95%CI: 12-24), bronchiectasis in 5% (95%CI: 3-10), emphysema in 5% (95%CI: 0-45), and Eisenmenger's syndrome in 4% (95%CI: 2-8). HT indications included ischemic heart disease in 40% (95%CI: 33-47), nonischemic disease in 39% (95%CI: 25-56), and retransplantation in 10% (95%CI: 1-59). The pooled mean pulmonary vascular resistance (PVR) in HT recipients was 3.05 Woods units (95%CI: 0.14-5.95). The overall mortality in the HLT group was 28% (95%CI: 18-41) at an average follow-up of 15.7 months (95%CI: 0.82-30.5), and 35% (95%CI: 17-58) in the HT group at average follow-up of 37.3 months (95%CI: 6.7-67.8). Freedom from rejection in HT was 94% (95%CI: 75-99) at 1 month, 77% (95%CI: 30-96) at 6 months, and 41% (95%CI: 33-50) at 1 year. A subgroup comparison between HLT and HT groups demonstrated a significant difference in the age [mean HLT age, 26.7 years (95%CI: 21.3-32.2) vs mean HT age, 40.4 years (95%CI: 32.2-48.6) p 0.01] and a trend towards significance in male sex [45% males in HLT group (95%CI: 29-63), vs 68% males in the HT group (95%CI: 52-80) p=0.06]. Pooled survival over time for both groups is shown in the figure. Conclusions:The domino procedure appears to be a viable option in properly selected patients that can be performed safely with acceptable outcomes.

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