To expand the cardiac donor pool, mitral valve surgery has been performed to repair significant donor mitral valve disease at the time of heart transplant [22–24]. Bench ring annuloplasty has been reported for tricuspid regurgitation with normal leaflet motion and annular dilation [22, 23]. Bench commissurotomy and DeVega annuloplasty have also been reported for organic mitral valve disease due to rheumatic process [24]. This author prefers to perform bench mitral annuloplasty for donor hearts at the back table using Kay-Reed annuloplasty [14, 15] only when the echocardiography at the donor hospital shows mild or greater mitral regurgitation before procurement of the heart.

Although significant mitral valve disease after heart transplantation is rare, the need of mitral valve surgery upon transplanted hearts is predicted to become more common with increasing longevity of heart transplant recipients and with efforts aimed at preserving cardiac allograft function to avoid cardiac re-transplantation since the donor shortage is the major limiting factor of heart transplantation [25, 26]. Unlike coronary arteries, the long-term function and structure of mitral valve has been shown to be preserved [27]; however, mitral valve repair and replacement have been reported upon transplanted hearts. Mechanisms of mitral insufficiency include left-sided endomyocardial biopsy, endocarditis, myxomatous degeneration, fibrosis of papillary muscles, and chordae tendineae due to rejection, allograft coronary artery disease leading to ventricular dysfunction with mitral annular dilation, and potential distortion of the mitral valve structure due to left atrium-to-atrium anastomosis [25–27]. Mitral valve surgery after heart transplantation can be performed with conventional techniques, indications, and outcomes.

Over the last decades, lung transplantation has become a viable treatment for a variety of end-stage lung disease with improved outcome due to better surgical techniques, organ preservation against ischemia/reperfusion injury, immunosuppression against rejection, and infection prophylaxis [32]. Currently, the major limiting factor is the shortage of donor organs. To maximize utilization of donor organs for lung transplantation, this author has recently reported how to harvest the donor lungs from patients who had undergone cardiac valve surgery [33]. Traditionally, patients with other significant comorbidities including cardiac diseases have been denied for lung transplant candidacy [3]. With the improved outcome in lung transplantation, however, a few centers have performed lung transplantation concomitant with cardiac surgery including coronary artery bypass, patent foramen ovale closure, atrial septal defect repair, ventricular septal defect repair, patent ductus arteriosus repair, replacement of the ascending aorta, and DeVega tricuspid valve repair [34–36]. Thus, in selected cases, cardiac problems including valvular heart diseases can be repaired at the time of lung transplantation.

Tricuspid regurgitation is the most common valvular disease in lung transplant recipients because patients frequently have pulmonary hypertension due to end-stage lung disease, and this elevated afterload makes the right ventricle dilated, resulting in tricuspid annular dilatation. However, whether we should operate on the tricuspid valve or not and when we should repair it are unknown at the time of lung transplantation. A group from Austria has reported that tricuspid regurgitation disappeared 3 months after double-lung transplantation in patients with primary pulmonary hypertension due to reverse remodeling of the right ventricle with normalized or reduced pulmonary vascular resistance [37]. Another group has also reported similar results after single-lung transplantation for pulmonary hypertension [38]. However, the mortality rate at 3 months after lung transplantation was 17.5 % [37], and the most recent International Society of Heart and Lung Transplantation Registry data show that primary pulmonary hypertension has the lowest survival immediately after lung transplantation in the major diagnostic categories with initial evident separation in survival between primary pulmonary hypertension and chronic obstructive lung disease and cystic fibrosis [32]. The registry speculates that this initial difference in survival may be related to differences in the complexity of the surgery and the frequency and severity of early complications [32]. This author speculates that this high early mortality in primary pulmonary hypertension is related to heart failure, predominantly right heart failure with tricuspid regurgitation leading to multiple organ failure. It is well documented that right heart failure manifests as enlarged right atrial size due to high right atrial pressure and the severity of tricuspid regurgitation predicts mortality in primary pulmonary hypertension [39]. Severe tricuspid regurgitation is the indication for repair or replacement to improve survival either as an isolated disease or as functional tricuspid regurgitation associated with left-sided valvular diseases [40]. In this author’s institution, tricuspid valve repair concomitant with double-lung transplantation is the procedure of choice for patients with primary pulmonary hypertension with severe tricuspid regurgitation, and with this strategy for primary pulmonary hypertension, from 1994 to 2006, the institution’s survival rate is 86 % at 1 year, 75 % at 5 years, and 66 % at 10 years, which is better by 20–39 % compared to the 23rd official report from the registry of the International Society of Heart and Lung Transplantation data from 1994 to 2004, which is 66 % at 1 year, 39 % at 5 years, and 27 % at 10 years [41]. This author believes the importance of tricuspid valve repair at the time of lung transplant for severe tricuspid regurgitation in improving early survival after lung transplantation.