Combined heart-lung transplantation has been performed in 51 patients since 1984. A pulmonary preservation fluid preceded by prostacyclin infusion has allowed distant procurement. Early organ function has been good in all cases. Maintenance immunosuppression is cyclosporine and azathioprine. Steroids are given to treat rejection episodes. Transbronchial biopsy has allowed the accurate, early and safe diagnosis of rejection. Acute cardiac rejection has not occurred in these patients. Thirty-seven patients are alive between 1 and 54 months following transplantation. The actuarial survival at 1 year is 76% and 68% at 2 years. Four patients died in the early postoperative period as a result of primary Cytomegalovirus (CMV). Other causes of early death were bacterial infection (4), cerebrovascular event (1), tracheal dehiscence (1) and small bowel infarction following retransplantation for obliterative bronchiolitis. Three other patients have died as a result of obliterative bronchiolitis. Patients and donors have been carefully selected to ensure that this scarce resource is utilised most effectively.