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HE RESULTS of single lung transplantation in patients with severe pulmonary emphysema have been poor. Most of the patients have died within a few weeks of operation from respiratory insufficiency produced mainly by a serious ventilation-perfusion (V/Q) imbalance.21,22,30 The latter has been characterized by underventilation of the transplant despite the fact that it has been receiving most of the pulmonary blood flow.19 Because the classic histologic manifestations of rejection were not present in the allografts, this V/Q imbalance, which produces a high degree of venous admixture with severe arterial hypoxemia, has been widely attributed to the physiologic setting in which a transplant with normal vascular resistance, airway resistence and compliance exists in parallel with an emphysematous lung which has a high vascular resistance, a high static compliance and a high expiratory airway resistance. Theoretically this physiologic setting alone could account for the distribution of most of the blood flow to the transplant while the emphysematous lung received the majority of the ventilation, became overexpanded, and compressed the already poorly ventilated transplant. On this basis, single lung transplantation has been deemed contraindicated in emphysematous patients, and bilateral procedures have been advocated despite their increased complexity.1'30

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