Sarcopenia, the reduction in muscle mass and function [37], is a relevant risk factor for waiting list mortality in patients undergoing HTx. Roehrich et al. [38] showed that the muscle area of the erector spinae muscle appears to be a risk factor for death in patients on the waiting list for HTx. The preoperative pectoralis muscle size and attenuation in CT scans are predictors of outcomes after the implantation of a left ventricular assist device (LVAD) [39].

The placement of a mechanical circulatory support device (MCSD) to aid physical therapy in advanced heart failure patients suggests that approximately 50% of the patients show improvement in their frailty level [40]. Chicano-Corrales et al. [41] demonstrated that patients with MSCD on the waiting list for HTx have high mobility, better 6-min walking distance (6MWD), shorter periods of invasive mechanical ventilation, and better nutritional status.

The use of an LVAD can improve frailty. Chung et al. [19] found that frailty was reversed after LVAD implantation, with 45% of patients improving their hand grip strength 6 months after implantation. Implementing LVAD in heart failure patients has been associated with decreased frailty. ECMO patients are the most challenging patients for pre-habilitation. Venous cannulation from the upper body, arterial cannulation in the axillary artery, and double-lumen cannulas for veno-venous ECMO or Oxy-RVAD should always be privileged to keep the patient active and avoid the shifting toward disability.

In selected patients, poor functional status related to end-stage pulmonary disease may be improved by adding veno-venous ECMO (VV ECMO). This approach avoids the complications associated with prolonged intubation and ventilator-associated lung injury. Several cohort studies and case series have demonstrated the feasibility and safety of a strategy that maximizes the opportunity for mobilization when active physical therapy is combined with awake, non-sedation, and non-paralytic protocols [18, 42, 43].

Several clinical trials have shown the beneficial effects of physical therapy in improving frailty by increasing muscle mass. The REHAB-HF trial [20] in a small cohort of patients demonstrated an improvement in the SPPB index and the 6MWD at three and 6 months after the intervention. The exercises included static and dynamic balance training, mobility training, functional strengthening of the lower extremities, and endurance training.

LTx candidates typically have decreased muscle mass, strength, and function, which are associated with worse outcomes [44] and a higher risk of 1-year mortality [45, 46]. The 6MWD is a suitable index for determining baseline physical functioning in various patient populations with chronic illnesses and it is associated with higher rate of mortality and worse outcomes after LTx [47]. Despite this, its role in predicting post-transplant outcomes remains uncertain. A study analyzing over 9,500 lung transplant recipients found that although 6MWT distance was significantly associated with post-transplant survival, relying on a single, dichotomous value [47] (e.g., above or below a specific distance) was limited in predicting outcomes. This suggests that 6MWT should be considered on a continuous basis rather than using arbitrary cutoffs

Lung function, as measured by VO2max, is associated with post-transplant survival and outcomes. Bakelants et al. [21] showed that lower pretransplant VO2 max is associated with worse lung function and 3-year mortality after LTx.

Several studies have demonstrated the effects of physical therapy and respiratory physiotherapy [48]. The addition of the inspiratory muscle training [49] increased 6MWD by 100 m, improved the alveolar volume ratio of carbon monoxide diffusion capacity and maximum inspiratory pressure, and decreased the dyspnea score.

Malnutrition, resulting from insufficient energy and protein intake or hyper-catabolism, is frequent in patients who have been transplanted or are awaiting transplantation.

Routine nutritional screening is useful. The use of BMI as a metric of nutritional status is advantageous due to its ease of use, and correlation to outcomes based on BMI extremes. However, the use of BMI alone may lead to miscalculation of a candidate’s true nutritional status [50].

The prevalence of heart failure-associated malnutrition is estimated to be up to 70%, with 15%–50% of patients globally being cachectic. Malnutrition is an independent risk factor for postoperative complications and mortality after HTx [51]. Nutritional supplementation has been reported to be beneficial for candidates for HTx. In a meta-analysis, Veronese observed that multi-nutrients significantly improved handgrip strength and chair rise time in frail/sarcopenic elderly patients [23].

The incidence of malnutrition in waitlisted LTx patients is near 40%. It is an independent risk factor for waitlist and post-transplant mortality [52, 53]. Congedi et al. [54] found a correlation between pre-transplant serum albumin values and the duration of invasive mechanical ventilation and ICU stay.

Patients with cystic fibrosis (CF) often experience malnutrition due to factors like malabsorption and increased energy expenditure. A high-calorie, high-fat, nutrient-dense diet is recommended to meet their energy and nutritional needs. Despite aggressive nutritional interventions, studies have shown limited improvements in body mass index (BMI) or fat-free mass before transplantation [55]. Systemic sclerosis (SSc) patients frequently face gastrointestinal complications leading to malnutrition, which can adversely affect transplant eligibility and outcomes. Comprehensive nutritional assessments are essential to identify deficiencies and implement appropriate interventions [56]. In both CF and SSc populations, individualized nutritional plans and close collaboration with dietitians are imperative to optimize transplant success and enhance patient outcomes.

Optimal and individualized nutritional management thus appears indispensable both pre- and post-transplant. Boura [22] applied the recommendations of the French Speaking Society of Clinical Nutrition and Metabolism to pre- and post-transplant patients and observed maintenance in BMI. Nutritional management of LTx candidates and recipients should include a global nutritional assessment to correct or prevent nutritional deficiencies, support the healing process for surgical wounds, and optimize nutrient stores to strengthen the immune system. In certain patients, such as those with CF or SSc, percutaneous endoscopic gastrostomy (PEG) tubes play a crucial role in managing malnutrition, particularly when oral intake is insufficient. Studies have demonstrated that PEG feeding is well-tolerated in CF patients, leading to significant improvements in weight, body mass index, and stabilization of pulmonary function over time [57]. Patients with SSc who underwent PEG insertion experienced substantial weight gain and enhanced nutritional parameters. Moreover, PEG feeding can be crucial in managing severe swallowing dysfunction in SSc, providing a reliable route for nutrition when oral intake is compromised [24].

Depression, anxiety, and general distress are common among cardiothoracic transplant candidates and persist in many patients following transplantation. Psychosocial evaluation and support enable care planning and the provision of interventions to improve patients' viability as transplant candidates and facilitate post-transplantation care to support optimal psychosocial and medical outcomes.

The transplant candidate faces various events and stressors throughout the evaluation and waitlist periods. Specific stressors associated with the evaluation include uncertainty about suitability for transplantation and concerns about changes to future life plans. Smith et al. [58] found that depression and distress were associated with increased mortality.

The guidelines for ERAS in thoracic surgery [6] strongly recommend counselling and patient empowerment. Rosenberg [23] defends cognitive-behavioral therapy as a way to reduce psychosocial distress.

An extended, holistic, and comprehensive role for anesthesia care is needed throughout the entire perioperative period in the ERAS era for cardiothoracic transplantation. The new trend focuses on preserving allograft quality, maintaining cardiovascular stability, and preventing extrapulmonary complications [26].

Minimally invasive surgery (MIS) is the gold standard approach in thoracic surgery. MIS shows significantly lower morbidity rates and shorter hospital stays in patients undergoing VATS lobectomy compared with open thoracotomy [6]. Fischer [64] described in 2001 the video-assisted minimally invasive approach in bilateral LT. Marczin [65] and Thomas [29] demonstrated better outcomes, showing less blood or platelet transfusion, decreased median days of MV, shorter ICU LOS, and improved lung function after transplantation. Emerson [66] described the first eight cases of robotic lung transplantation with similar outcomes.

In cardiac surgery, minimally invasive cardiac surgery has increased in prevalence, showing less hospital mortality, lower 30-day mortality, fewer renal complications, postoperative infections, and atrial fibrillations in some minimally invasive approaches such as valve replacement. [67, 68]. However, in heart transplantation, the only significant attempt to reduce the biological impact of the surgery is to minimize the use of cardiopulmonary bypass to the strict necessary switching to ECMO as soon as it is required and reducing the blood losses to reduce the need of blood products [69].

The choice of the correct anticoagulant, the sparing of vasodilators in patients on the High Urgency List to reduce the risk of postoperative vasoplegia, and the proactive management of preoperative anemia are valuable strategies during the waitlist period. Careful separation using pre-emptive ECMO support may avoid dreadful prolonged phases of postoperative low-output states requiring fluids, vasoconstrictors, and the need for postoperative continuous renal replacement therapy (CRRT) [70, 71] From this perspective, the team managing the recipient must design the patient’s entire journey, considering the risks related to the organ allocated, its preservation, the donor-recipient matching, and the recipient’s features.

The use of intraoperative extracorporeal life support (ECLS) in lung transplantation is a controversial issue. Strategies vary from center to center, ranging from off-ECLS to CPB or ECMO (V-V or V-A). The International Consensus Recommendations for Anesthetic and Intensive Care Management of Lung Transplantation [26] recommend avoiding cardiopulmonary bypass during LTx when it’s possible. However, using ECLS should not be delayed in severe and ongoing cardiorespiratory instability cases.

The American Association for Thoracic Surgery expert consensus [72] suggest that the use of routine V-A ECMO should be implemented in lung transplantation in order to control the graft reperfusion and decrease PGD, however they accept the need of randomized prospective clinical-trial to confirm it [70]. Van Slambrounck et al. [73] demonstrated in a retrospective study the benefit of right-first implantation to reduce PGD grade 3 without ECLS. They defend [74] the benefit of holistic approach increasing the space thanks to ribs and diaphragm retraction, arterial clamping probe and gradual reperfusion, short clamping left atrium avoiding external compression and short implant time.

The use of V-A ECMO instead of CPB has shown improved rates of PGD and decreased rates of morbidity [30].

Successful weaning from ECLS after cardiothoracic transplantation is a critical process influenced by various factors. Studies have highlighted that implementing standardized protocols, such as a stepwise weaning protocol guided by echocardiography, can significantly improve weaning success rates and patient outcomes [31] Factors affecting successful weaning include daily echocardiography, circulatory support with dobutamine, longer ECLS duration, older age, female gender, low preoperative glomerular filtration rate, and hemodynamic monitoring post-extracorporeal cardiopulmonary function [75]. Integrating these findings into an ERAS process for cardiothoracic transplantation could enhance successful weaning outcomes by focusing on tailored protocols, comprehensive monitoring, and patient-specific factors.

Patients who cannot wean off ECMO may benefit from the awake ECMO strategy, allowing them to remain physically active and avoid the complications associated with invasive mechanical ventilation. Studies indicate that this approach leads to better postoperative outcomes, such as shorter ICU stays, more ventilator-free days, and improved physical condition [32], thus aligning well with ERAS goals of promoting early mobilization and recovery.

Optimal pain management post-cardiothoracic transplantation is crucial for patient outcomes. Multimodal pain management strategies, including regional anesthesia and systemic analgesics, are recommended to reduce postoperative morbidity and mortality. The postoperative pain treatment is crucial for early rehabilitation. Effective treatment involves regional analgesia combined with a multimodal approach as quickly as possible orally. Thoracic epidural analgesia is often considered the gold standard due to its effectiveness and associated benefits, although some prefer less invasive techniques like chest wall blocks. The use of these regional analgesia techniques aims to minimize opioid use, enhance patient comfort, and promote faster recovery [33, 76].

Early extubation of patients may benefit from early analgesia strategies with continuous local anesthetic infusion, while those remaining ventilated may have delayed regional analgesia.

Recent research on chest tube management after thoracic transplantation highlights the importance of standardizing protocols to optimize patient outcomes and reduce recovery time. In thoracic surgery, the key elements include minimizing the duration of chest tube placement, promoting early mobilization, and utilizing modern drainage systems. Batchelor [6] highlights the importance of early chest tube removal, no routine suction, and the use of digital drainage systems to monitor and manage air leaks and fluid outputs. This approach facilitates early mobilization and reduces the need for opioid analgesia, contributing to better postoperative outcomes [77].

Early mobilization and physical therapy are critical components of postoperative care in thoracic transplantation, playing a vital role in ERAS protocols. They enhance physical and mental recovery, reduce complications, and contribute to a quicker and more efficient recovery process. Early mobilization, involving out-of-bed activities and ambulation, helps to maintain physical fitness and reduces the risk of complications such as respiratory infections and muscle atrophy.

In the context of ECMO for cardiopulmonary failure, early mobilization has been shown to be safe and feasible, even with femoral cannulation, and is associated with improved transplant outcomes [34].

Postoperative physical therapy significantly improves skeletal muscle function, exercise capacity, and quality of life. Rozenberg [15] highlighted that rehabilitation programs are beneficial in optimizing physical function and aiding recovery postoperatively. Weight gain, hypertension, diabetes, dyslipidemia, and hyperglycemia rank among the five most common morbidities after lung transplantation. Exercise training and regular physical activity may be effective in reducing the incidence of metabolic syndrome [78].

Respiratory physiotherapy plays a significant role in managing patients after thoracic transplantation, particularly lung transplantation, by improving lung function, exercise tolerance, and overall quality of life.

Kerti et al. [79] demonstrated significant improvements in chest wall expansion, lung function, and quality of life markers with perioperative pulmonary rehabilitation in lung transplant patients.

Post-operative nutritional support can enhance recovery, reduce complications, and improve the quality of life for HTx and LTx patients.

Anbar et al. (2003) emphasized the importance of early postoperative nutritional support in improving wound healing and reducing infection rates in transplant recipients. Data from Lopez-Baamonde [80] demonstrated the effectiveness of a prehabilitation multimodal program based on an intervention designed to enhance functional capacity (with exercise training and promotion of physical activity), nutritional counseling (and supplementation), and psychological resilience Ikeda et al. [35] demonstrated that early postoperative nutritional support following LTx helps to suppress weight and muscle loss, thereby enhancing recovery. The comprehensive care outlined by Sriram [81] and Francisco José et al. (2012) further underscores the necessity of nutritional optimization in preventing malnutrition, muscle wasting, and infection, which are critical for the successful outcome of thoracic transplants. Bannister (2014) highlighted the role of nutritional support in promoting growth and energy balance in pediatric HTx recipients, showing improvements in weight-for-age and a transition from tube to oral feeding post-transplant.

Starting enteral feeding within 48 h after transplantation helps to minimize the stress response and maintain gut integrity with high-protein, caloric-dense formulas to meet the increased metabolic demands with supplementation with essential vitamins and minerals to support healing and immune function. When enteral nutrition is not feasible, a balanced mix of amino acids, lipids, glucose, vitamins, and minerals tailored to the patient’s need for parenteral formula should start as soon as possible [35, 81].

Posttransplant psychological interventions are crucial as they directly influence medical outcomes and overall recovery. Recommendations highlight the importance of addressing psychological domains during the posttransplant recovery period, as illustrated in the works of Patel and Chernyak [82], who emphasize the need for comprehensive psychological rehabilitation. Moreover Sher [36]discusses the persistent challenges of depression and anxiety post-transplant and their effects on graft survival and patients. Integrating psychosocial support into pulmonary rehabilitation programs, both pre- and post-transplant, further underscores its importance in reducing stress, improving adjustment, and ensuring better clinical outcomes.