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Purpose Whereas double lung transplantation (LTx) is a preferred surgical option for the patients with secondary pulmonary arterial hypertension (SPH: defined as a mean pulmonary artery pressure (mPAP) above 25 mmHg), our institutional experiences have demonstrated the unique values of single LTx for SPH. Here, we review our experiences prioritizing single LTx for SPH in an attempt to optimize their opportunities and decrease mortality while waiting. Methods A retrospective review of the LTx database was used to identify patients who underwent single LTx. SPH patients were stratified into mild SPH (mPAP: 25-40 mmHg) and severe SPH (mPAP > 40 mmHg). Recipients without PH transplanted over the same time period were used as controls. Data are reported as severe SPH vs. mild SPH vs. controls. Results Three hundred eighteen patients received single LTx between January 2017 and December 2019. There were 217 patients with mild SPH (mPAP of 32 mmHg), 59 patients with severe SPH (mPAP of 46 mmHg) and 42 patients without PH (controls). There were no significant differences among the groups in their patients’ characteristics except higher pulmonary vascular resistance noted in severe SPH group and morbid obesity noted in mild and severe SPH groups. While severe SPH group required more intraoperative cardiopulmonary support (37.3% vs. 11.1% vs. 5.0%, p Conclusion Our experience supports the option of single LTx for the patients with even severe SPH by utilizing appropriate mechanical circulatory support intraoperatively. In light of the ongoing donor lung shortage, this strategy should be considered for optimizing organ utilization and decreasing waitlist mortality.

Purpose There is a hesitancy to use older donor lungs in lung transplants, and to perform them in older patients. To invalidate the use of donor and recipient age as relative contraindications for lung transplantation, we examined both, and factored in transplant type, then analyzed their effects on survival outcomes using propensity matching. Methods Patients were stratified by recipient age ( Results Using 743 lung transplant patients at our single center over 8 years (Feb-2012 to Mar-2020) in the pre-propensity match, there was a significant difference in survival outcomes for the group: ≥50 donor age ≥70 recipient age group in survival when looking at single vs. double lung transplant (p = 0.038). There were no other statistically significant differences in survival based on donor and recipient age, or transplant type. Post-propensity matching, there was no difference in survival based on the interplay between donor and recipient age, for donor group ≥50 (p = 0.092), for donor group Conclusion While donor and recipient age are undoubtedly important factors to consider during lung transplantation, neither of these independently affects long-term survival. Upon matching, there was no differences in survival for lung transplant patients based on transplant type. Older lungs and older patients can result in reasonable post-transplant outcomes.

Purpose Currently the continuous suturing technique is used on the bronchial anastomosis during lung transplantation. This study investigated that technique vs. the interrupted suturing technique, comparing survival and occurrence of post-operative bronchial complications to examine if a switch in technique is merited. Methods Survival outcomes of 721 single-center lung transplant recipients over 8 years (Feb-2012 to Mar-2020) were compared. Continuous suturing technique was performed with 3/0 polypropylene suture on an SH needle. Interrupted used the same technique for the membranous portion of the anastomosis and multiple interrupted 2/0 polypropylene sutures for the cartilaginous portion. Clinical parameters and demographics were compared. The two groups were compared for post-operative morbidity and survival was compared using Kaplan-Meier curves. Log-rank tests were performed, as was Cox regression analysis, with p Results Of the 721 patients, 429 received the continuous suturing technique while 292 had interrupted suturing technique. Demographics and clinical parameters compared were: age (p=0.008), gender (p=0.643), race (p=0.268), etiology (p Conclusion Although both techniques showed reasonable post-transplant outcomes, our study indicated better survival and relatively fewer complications when using interrupted suturing technique vs continuous. Further long-term study of similar groups with similar long-term follow up in these two groups should be performed to validate this effect.

Purpose Donation after circulatory death (DCD) is propagated to expand the lung transplant (LTx) organ donor pool. Using the International ECLS Registry database, we compared DCD vs DBD LTx survival in the context of intraoperative extracorporeal life support (ECLS). We hypothesize comparable survival outcomes and ECLS usage between donor groups. Methods Patients undergoing double-lung transplant were included from multiple institutions in US & Europe. Patients were stratified by donor type (DCD, DBD). Differences between groups in ECLS usage (yes/no) were analyzed with Chi-square testing or Fisher's exact test. Donor, recipient, and procedural characteristics, including the primary outcome of post-operative survival, were analyzed using Wilcoxon rank sum test or Chi-square testing. Propensity matching was used with Kaplan-Meier survival curves and log-rank testing to assess mortality between groups with and without ECLS. Endpoints Analysis of differences in patient/donor demographics, pre-operative, intra-operative and post-operative ECLS usage, post-operative complications, and patient survival will be used to compare the DCD and DBD donor groups. A total of 866 double lung transplantations (DLT), 72 DCD and 794 DBD cases, were preliminarily analyzed. DCD had older mean donor age (p=0.003), and higher post-operative pneumonia rates in DCD (p=0.01). Groups were different in the type of intra-operative ECLS support required (CPB, ECMO, Modified bypass) (p=0.014), total ischemic time (p=0.0001), and post-op ECMO (p=0.06). Mortality analysis showed no increased risk for DCD vs DBD groups before discharge (HR 1.31; CI- 0.43, 3.96; p=0.63), at 90-days (HR 1.49; CI- 0.35, 6.31; p=0.58), and 1-year (HR 0.93, CI-0.33, 2.60; p=0.89). Figure shows KM curves before and after propensity matching with/without ECLS. Further analysis will be done as the ECLS Registry patient volume increases.

Purpose Donor after cardiac death (DCD) is an organ procurement method that is being increasingly used to expand the current lung donor pool. We hypothesize that in our single-center study, DCD and donor after brain death (DBD) groups would have similar survival rates as found in previous studies. Methods A retrospective analysis was performed at a single center which identified 801 lung transplants completed between March 2012 and September 2020. DCD LTx patients (n=18) were matched by propensity scores with donors after brain death DBD recipients. Propensity scores (PS) were determined using patient age, sex, race diagnosis, BMI, and donor age. PS matching was done by comparing 1:1, 1:2, and 1:3 pooled groups (DCD:DBD), and performing either chi-squared or t-tests analyses on each variable before and after matching. Survival outcomes were calculated using Kaplan-Meier curves and log-rank tests. Results Of the 801 LTx patients, mean donor age for DCD lungs was 27.59. The PS matched DBD group did not significantly differ from the DCD group in age (p=0.6339), sex (p=0.401), race (p=0.846), diagnosis (p=0.102), pump use (p=0.867), BMI (p=0.0467) or donor age (p=0.8275). Log-rank testing with Kaplan-Meier curves of pre-PS matching revealed no significant survival difference between DCD and DBD groups (p=0.38). The PS matched data similarly found no significant difference in patient survival (p=0.26) which was consistent across the 1:1, 1:2 and 1:3 matched groups. Conclusion Our study found both DBD and DCD donor lungs provide comparable short-term survival outcomes. This is in agreement with previous studies, which argue for the viability of DCD donor lungs and for their use to be expanded.

Purpose The lung transplantation (LTx) community continues to investigate single- (SLT) vs. double-lung transplantation (DLT) to predict optimal long-term survival post-LTx. We investigated the survival in younger patients receiving SLT using the current United Network for Organ Sharing (UNOS) database and our single center results. Methods A retrospective analysis of both UNOS and single center databases was performed, investigating patients between ages 18 and 50 who received either a SLT or DLT from August 2005 to March 2020 (n=11156; n=48). Similar patients were matched between the two databases (n=96). Survival outcomes were assessed before and after propensity score matching. P-value Results In the pre-propensity match, the UNOS patient group who received DLT had better survival outcomes than SLT (p Conclusion While debate continues on the validity of SLT vs. DLT continues, transplantation type did not affect long-term survival in any patient group. Upon matching, there was no difference in survival for lung transplant patients based on transplant type. These promising newer results support consideration of the use of SLT, which allows for greater distribution of limited donor organs.

Purpose Prior single center experiences suggest that use of ECLS during lung transplantation (LT) increases the risk of PGD. Here we analyze the effects of intraoperative ECLS time on PGD after LT in a multicenter ECLS registry. Methods The ECLS in LT registry includes data on bilateral LTs from 8 centers (2 from Europe, 6 from United States). The registry excludes single lung transplants and multi-organ transplants and defines primary graft dysfunction according to the ISHLT 2016 consensus statement. Herein, we refer to PGD as a single case developing PGD3 at time 48 and/or 72 hours. We explored the risk of intraoperative ECLS time on the incidence of PGD and death within 90 days using adjusted and unadjusted logistic regression and receiver operating curve (ROC) analysis. Results We identified 297 ECLS patients with intraoperative support times available between January 2016 and August of 2019. Breakdown of cases were as follows: 44% CPB, 66% ECMO (16% VV, 64%VA/VVA, 20% modified bypass-VA). Out of these, 35.6% developed PGD and 6% died within 90 days. Median time of ECLS support was 206 minutes (62-686 minutes). The median time of support was 200 minutes in patients without PGD and 206 minutes in cases with PGD. The median time of support was 202 minutes in patients who survived 90 days compared to 271 minutes in patients who did not survive 90 days. Our unadjusted and adjusted logistic regression analysis showed that time of ECLS was not associated with PGD irrespective of the mode of ECLS (CPB v ECMO). In addition, ROC analysis showed an area under the curve for ECLS time of 0.51 suggesting poor predictability for PGD. Our unadjusted analysis showed that increased time on ECLS was significantly associated with death within 90 days (P=0.014) although this was of borderline significance after adjusting for risk factors (P=0.067). Furthermore, this effect was of borderline significance for CPB (P=0.07) and not significant for ECMO (P=0.17). Conclusion In an international multicenter registry on use of ECLS in LT, the time on ECLS did not alter the risk of PGD with either CPB or ECMO, although it was associated with perioperative death. Surgeons should limit the time spent on ECLS when feasible and consider ECMO for longer procedures.

Purpose Heart transplantation (HTx) is routine in many eligible patients of different ages including elderly. We investigated the 5 year to 10 year survival outcomes of elderly heart transplantation patients by analyzing the UNOS database. Methods 51,899 patients underwent heart transplantation that were reviewed from the UNOS database (1987-2014). HTx patients were divided into two different age groups based on recipient age, Results Out of 51,899 HTx patients, 51,165 were Conclusion Older heart transplant recipients started to showed gradually increasing statistical separation from the 8th year post-HTx, favoring the younger cohort. However, survival of elderly patients (≥70) to estimated 10 years survival is still a fair probability.

Purpose Coronary artery disease (CAD) has been considered a relative contraindication for concomitant cardiac surgery during lung transplantation. We investigated a cohort of older patients who underwent concomitant coronary artery bypass grafting (CABG) with lung transplantation, to determine whether surgical outcomes were acceptable. Methods Lung transplant procedures with concomitant CABG between March 2012 and July 2019 were retrospectively analyzed. The patients investigated were over 70 years of age.Patients were propensity score-matched by pre-transplantation variables. Outcomes between these two groups were then compared; once using the entire cohort, and once using the propensity score-matched patients. Survival was compared by Kaplan-Meier curve and log-rank tests. Results There were 7 patients aged 70 or older that underwent concomitant CABG with lung transplantation. These 7 patients were 1:3 propensity score-matched with 21 of the 166 patients that did not undergo concomitant CABG. There was no statistically significant difference in survival outcomes between patients over 70 that underwent concomitant CABG and patients over 70 that did not undergo concomitant CABG (p=0.77). When analyzing the two groups after propensity score matching, there was still no statistically significant difference in survival outcomes (p=0.73). Overall survival for patients over 70 that underwent concomitant CABG was 100% at 90 days, 86% at 1 year, and 72% at 3 years. Overall survival for patients over 70 that did not undergo concomitant CABG was 93% at 90 days, 85% at 1 year, and 66% at 3 years. Conclusion Patients over 70 that underwent concomitant CABG with lung transplantation showed no significant difference in survival outcomes when compared to patients over 70 that did not undergo concomitant CABG. Considering this data, patients over 70 with CAD would be reasonable candidates for concomitant CABG with lung transplantation in selected cases.

Purpose Following a combined heart/lung transplant (HLTx), UNOS reports a survival rate of 68% at year 1, 58% at year 2, and 53% at year 3. This study aims to compare the survival outcome following HLTx from our medical center with UNOS registry data. Methods We retrospectively studied 12 patients that underwent HLTx at our center between 2012-2020 to assess long-term survival. We analyzed included recipient's age, sex, etiology, lung allocation score (LAS), cardiopulmonary bypass (CPB) time, total/warm ischemic time, procedural approach, induction, donor age/sex, length of stay (LOS), and cause of death. We then assessed the survival outcome of our patients and compared that with the UNOS registry data (n=1295) using a Kaplan-Meier curve and log-rank test (p Results Out of our 12 patients, 8 were male and 4 were female, with the average age 53 ± 10 yrs. From the donors, 7 were male and 5 were female, with an average age of 37 ± 14 yrs. Etiology included PF (50%), sarcoidosis (17%), and pulmonary HTN (17%). Pre-Txp, 2 patients were placed on VA ECMO (1 on ventilation), 1 on VV ECMO, 1 on RVAD, and 1 on HM III. The average LAS was 65 ± 21. All of our patients were put on CPB during operation with an average CPB time of 186 ± 37 min, total ischemic time of 243 ± 68 min for right and 194 ± 60 min for left, and warm ischemic time of 36 ± 10 min for right and 47 ± 11 min for left. In total, 9 had a median sternotomy incision and 3 had a clamshell incision. Campath induction was performed on 7 patients while 5 had Simulect induction. Post-Txp, 2 patients required ECMO. Median LOS was 45 days and mean survival time was 757 ± 945 days. A total of 3 patients died due to infection, MSOF, and bleeding. The log-rank test between the patients from our center compared to the national average showed no significant difference in survivability (p=0.292). Conclusion Although not significant, our HLTx survival outcome was slightly better than the national UNOS survival data. Surgical techniques and careful management may contribute to better survival outcomes in selected patients.

Purpose Idiopathic pulmonary fibrosis (IPF) accounts for the largest proportion of diagnoses on the US lung transplant (LTx) list. LTx type (single vs double) and donor age are associated with differences in outcomes, yet their independent and combined effects in patients with IPF remain unclear and are investigated in this study. Methods This study retrospectively analyzed survival of patients with IPF receiving LTx at a single center from Feb-2012 to Mar-2020. LTx recipients were grouped by single (SLT) or double (DLT) LTx type and donor lung age Results Of 742 LTx patients, 305 (41%) were diagnosed with IPF, of which 204 (67%) were SLT and 97 (32%) were DLT (4 patients underwent either heart-lung transplant or single-sequential LTx and were excluded). There was no significant difference in survival due to LTx type (p=0.368). Similarly, no significant difference in survival was found for patients with donor age Conclusion Demand for donor lungs far exceeds supply, and with IPF accounting for a large percentage of this need, finding effective sources of supply has become increasingly important. Use of SLT and donors aged 50≥ can serve as important supply sources with non-inferior survival outcomes.

Purpose In 2013, the US Public Health Service (PHS) established new guidelines for high risk donor organs and renamed the category “increased risk” (IR). We compared survival outcomes of lung transplant (LTx) patients that received either IR or non-IR donor lungs to determine if IR donor lungs are an underutilized resource. Methods This study retrospectively analyzed and compared survival and utilization rates of IR and non-IR donor lung recipients at a single center from Feb-2012 to Mar-2020. LTx recipients were stratified by PHS IR status of the donor lung(s) received. Survival of IR and non-IR donor lung recipients was assessed using Kaplan-Meier (KM) survival analysis and compared by log-rank test. Cox proportional hazards modeling was used to control for variables significantly associated with IR/non-IR status, including recipient race, average warm ischemic time, transplant type, and donor age. Results Of 742 LTx patients at the center (Feb-2012 to Mar-2020), there were 193 (26%) recipients of IR organs. In 2012 and 2013, 7% and 0% respectively of the lungs transplanted at the institution were IR labeled. After the PHS guidelines were nationally implemented in Feb-2014, the proportion of IR labeled lung transplants rose to 8% (2014), 26% (2015), 40% (2016), 53% (2017), 38% (2018), and 37% (2019). Median survival times were 1.8 years for IR and 2.0 years for non-IR LTx recipients. KM survival analysis and log-rank test comparison showed no statistically significant difference in survival between IR and non-IR donor lung recipients (p = 0.606) over the 8-year period. Cox regression controlling for significant variables suggested none of the covariates significantly affected survival. Conclusion While the 2013 guidelines caused a sharp increase in lungs labeled IR, our survival analysis suggests the criteria may be misleading and of little help when assessing risks and estimating probability of survival. IR designations risk underutilization of viable lungs, a serious concern considering the waitlist demand for donors.

Purpose Cold ischemic time (CIT) may adversely affect clinical outcomes after lung transplantation (LTx). Most centers restrict CIT to less than 6-8 hours. However, to improve donor utilization, centers are increasingly pushing the envelope of CIT. To clarify the effect of CIT on graft function and clinical outcomes, we analyzed the international multicenter ECLS in LTx registry. Methods the ECLS registry collects LTx data from 6 US and 2 European centers between January 2016 and March 2020. Single LTx, ex vivo lung perfusion, and multiple organ transplants were excluded. CIT was analyzed as a continuous variable and divided in balanced tertiles. The reperfusion of the second lung was considered the end of the CIT. Models were adjusted by 11 clinical factors. Our endpoints were PGD at T0, T24, T48 and T72 hours according to the 2016 ISHLT consensus. Length of stay, death within 90 days and at one year of follow-up was investigated. A univariate and multivariate analysis was performed. Pearson correlation analysis was used to assess effect of CIT on length of stay (LOS). Results The inclusion criteria were met by 798 patients. The mean and median CIT was 418 and 397 min, respectively. Adjusted analysis suggests that total CIT was not associated with PGD grade 3 at 48 and 72 hours (OR1.24, 0.87-1.75). However, CIT was associated with several other markers of graft dysfunction and resource utilization including PGD3 T0 (OR1.5, 1.06-2.13), tracheostomy (OR1.93, 1.3-2.87), post-op ECMO (OR3.47, 2.21-5.45), renal failure requiring dialysis (OR1.8, 1.13-2.86), death within 90 days (2.41, 1.42-4.09), death in hospital (OR2.53, 1.47-4.35), and death within one year (OR 2.37, 1.43-3.94). Total ischemic time was also independently associated with LOS (P Conclusion In a multicenter international registry, increasing CIT was associated with increased PGD at T0, higher postoperative morbidity and worse first year survival. Although patients can be transplanted with extended cold ischemic times when absolutely needed, this practice is associated with greater resource utilization and likely impact on survival.

Purpose It remains unclear whether double lung transplantation (DLT) or single lung transplantation (SLT) is preferred for end-stage chronic obstructive pulmonary disease (COPD) patients. The purpose of this study is to examine the interplay between patient age and pulmonary artery pressure on survival after SLT vs DLT for COPD. Methods We performed a single-center retrospective study of lung transplantations for COPD between February 2012 to March 2020 (n=186). Demographics and clinical parameters were compared between patients based on their pulmonary artery pressure (PAP; PAP 65 years old) and PAP were analyzed using Kaplan-Meier curves and log-rank tests. Cox proportional-hazards regression was also performed. P-value less 0.05 was considered significant. Results Of the 186 COPD patients who received lung transplants, 71 (38.2%) received double-lung transplants and 115 (61.8%) received single-lung transplants. Demographics and clinical parameters between the two PAP groups showed significance in: lung allocation score (p=0.002) and BMI at time of transplant (p 65 years (p=0.723). The Cox model itself, also, did not show a statistically significant improvement in evaluating survival outcomes (p=0.126). Conclusion Lung transplantation outcomes in end-stage COPD patients demonstrated non-inferior results with SLT compared to DLT. When patients were differentiated based on PA pressure, adopting SLT or DLT did not show any survival differences.

Purpose Coronary artery disease (CAD) is not uncommon among lung transplant (LTx) and has been often carefully evaluated before LTx. Those who undergo these pre- and or post-lung transplantation percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG) procedures may be at risk to LTx short-term mortality. The survival outcome of prior or perioperative revascularization has not been adequately established. Methods A single-center retrospective analysis of all single and double LTx patients from Feb-2012 to Mar-2020 (n=748) was performed. Patients were split into 4 groups: (1) patients who received a preoperative PCI (Pre-PCI) (n=55), (2) those who received preoperative CABG (Pre-CABG) (n=38), (3) those who received concomitant CABG during LTx (Con-CABG) (n=47), (4) those who had LTx with no need for revascularization (n=607). Groups were compared for demographics, surgical procedure, and survival outcomes using STATA Inc. P-value Results The no revascularization group was statistically younger than the rest (P Conclusion Our results suggest that preoperative or intraoperative revascularization did not affect survival outcomes in lung transplant patients. Selected patients with coronary artery disease may benefit when intervened during lung transplant procedure.

Purpose Combined heart-lung transplantation remains the only definitive therapy for patients who have both end-stage heart failure and lung failure. We analyzed UNOS data for combined heart-lung transplant data to understand survival outcomes. Methods 1,294 patients underwent simultaneous heart-lung transplantation that were reviewed from the UNOS database between October 1987 and February 2020. Descriptives and frequencies were acquired for the variables height, weight, BMI, gender, ethnicity, age, donor age, ischemic time, length of stay, previous transplant, graft status, and creatinine level at the time of transplant were. Survival outcomes were obtained using a Kaplan-Meier Curve. The impact of all variables on survival outcomes was calculated using a cox regression. Data were expressed as mean ± std (SAS Inc). Results Out of 1,294 patients, 43.6% were male, 76.7% were Caucasian, 9.4% were African American, and 9.0% were Hispanic. 1.2% had experienced a previous transplant and 41.2% had a prior graft. Height was 160.0 ± 23.3 cm, weight was 59.1 ± 20.1 kg, BMI was 22.2 ± 4.9, age was 34.5 ± 15.3 years, donor age was 25.8 ± 14.0 years, ischemic time was 3.7 ± 1.2 hours, creatine levels were 1.0 ± .6 mg/dL, and LOS was a median of 26 days. The Kaplan-Meier Survival Curve showed 1, 3, 5, and 10 year survival outcomes of 68.5%, 53.1%, 44.7%, and 29.8% respectively. The cox regression showed a significant change in survival outcome from the inclusion of all variables (p=0.000). Only the variables graft status (p=0.000), donor age (p=0.002), and LOS (p=0.003) were significant. A prior graft increased the hazard ratio to 1.846, while the hazard ratios for donor age and LOS were 1.015 and 1.003 respectively. Conclusion In selected patients, for the last resort of the patients with end-stage cardiopulmonary failure, combined heart and lung transplantation remains a viable option for excellent outcomes.

Purpose Ex vivo lung perfusion (EVLP) improves organ quality and makes the lungs safe that were previously unsuitable for bilateral lung transplant (BLT). We investigated EVLP utilization in BLT from our ECLS registry and compared the outcome in DCD and DBD. Methods Patient data involving BLT were collected from the National ECLS Registry and stratified by EVLP in DCD and DBD. ECLS usage information was obtained and analyzed with Chi-square testing or Fisher's exact test to determine a relationship with donor groupings in EVLP. Lung transplant procedure details, patient and donor demographics and post-operative survival were analyzed using Wilcoxon rank sum test or Chi-square testing to determine distribution. Kaplan-Meier survival curves with log-rank testing to assess mortality between donor groups with EVLP use. P-values Results Out of 932 BLT, there were total 66 EVLP: 20 DCD and 46 DBD cases. Demographics data showed age:54±14 years, BMI 25 ± 5 kg/m2, 34M, LAS - 44±14, PHTN - 51 patients, prior ECMO - 2, donor age 38 ± 14, donor gender - 38M, total ischemic time - 578±149 min, Use of ECLS - CPB:7, ECMO:26, Modified bypass:8, Off-pump:25, PGD at 48h-72h - 18, Post-op ECMO: VA - 3, VV - 12, VVA - 1. Death before discharge - 9, before 90d - 5, before 1yr - 9. Tracheostomy - 15 patients, post-op pneumonia - 10 patients, median length of stay - 22 days. Unadjusted comparison reveals significant differences in 1yr survival with EVLP vs DBD vs DCD utilization (HR:2.16; CI- 1.00-4.66; p=0.05), but when adjusted, there were no significant differences (HR:0.93; CI- 0.33-2.60; p=0.883). Kaplan-Meier curve showed no statistical significance in DCD and DBD groups when used for EVLP. Conclusion EVLP utilization did not have any significant effect in survival when used in DCD and DBD transplantation. It suggests EVLP can be safely utilized in both groups thereby increasing the donor pool.

Purpose Prior studies have explored the effects of cold ischemic time on survival but its effect on PGD is unclear. The current study analyzed an international multicenter ECLS in lung transplantation registry to clarify the effects of cold ischemic time on PGD. Methods The ECLS in lung transplantation registry includes data on bilateral lung transplants from 8 high volume (>40 transplants/yr) transplant centers (2 from Europe, 6 from United States). This registry excludes single lung transplants and multi-organ transplants and the current analysis excluded Ex Vivo Lung Perfusion (EVLP) cases. We defined primary graft dysfunction according to the 2016 ISHLT consensus document and considered PGD3 at time 48 or 72 hours as high-grade primary graft dysfunction (PGD). We defined cold ischemic time as the interval between donor cross clamp (cardiac arrest for donation after circulatory death cases) and the longest reperfusion time in the recipient. We explored the effect of the cold ischemic time on PGD and death within 90 days using univariate and multivariate logistic regression analysis. Results We identified 511 entries with complete ischemic times between January 2016 and August of 2019. The overall incidence of PGD was 30.7%. The mean cold ischemic time in the group that developed PGD was 406 minutes and 428 minutes in the group that did not develop PGD. Univariate regression analysis showed no effect of ischemic time on the incidence of PGD (P=0.12). ROC analysis yielded an area under the curve for cold ischemic time and PGD of 0.55 further suggesting that cold ischemic time was poorly predictive of PGD. Our adjusted analysis showed no effect of total ischemic time on PGD (P=0.75). Finally, both univariate and multivariate analysis failed to show significance for the effect of total ischemic time on death within 90 days (P=0.33 and P=0.54, respectively). Conclusion In a large multicenter registry, we could not identify an effect of duration of cold ischemic time on incidence of PGD or 90-day mortality. Practitioners should avoid using cold ischemic times in isolation to accept or decline a potential organ, although its effects on early reperfusion and long-term graft function require further study as does the extent of tolerable cold ischemia.

Purpose The method of cardiorespiratory support used during lung transplantation (LTx) has been debated. This study serves to compare survival after LTx in patients who received support from either extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass (CPB). Methods We studied 565 LTx performed at a single institution between March 2012 and June 2019. Concomitant cardiac procedures were excluded. 118 underwent CPB, 49 underwent ECMO, and 398 were considered “off-pump”, as they received neither support. Comparisons between groups were performed using Chi-squared or ANOVA test. All significant variables from univariate analysis were included in a Cox regression analysis. Survival was assessed by Kaplan-Meier curve and compared by log rank test. P-values Results There was marginal survival difference (p =0.057) between the CPB, ECMO, and “off-pump” groups when analyzed together. When compared to the “off-pump” group in a Cox regression analysis, CPB (RR. 1.52, 95% CI: 0.99-2.31, p=0.054) and ECMO (RR. 1.71, 95% CI: 0.96-3.04, p=0.070) had borderline significant negative impact on survival. When compared amongst the three support groups, analysis of variances and Chi-squared tests showed no differences in recipient sex (p=0.089), race (p=0.42), donor age (p=0.69), donor type (brain death or donation after cardiac death) (p=0.59) and induction (p=0.38). The “off-pump” group was significantly older (p Conclusion This study demonstrates the borderline significance of CPB and ECMO impact on survival and warrants further exploration into the question of proper cardiorespiratory support in LTx.

Purpose Coronary artery disease (CAD) has been considered a relative contraindication for concomitant cardiac surgery during lung transplantation. We investigated a cohort of younger patients who underwent concomitant coronary artery bypass grafting (CABG) with lung transplantation, to determine whether surgical outcomes were acceptable. Methods Lung transplant procedures with concomitant CABG between March 2012 and July 2019 were retrospectively analyzed. The patients investigated were below 70 years of age.Patients were propensity score-matched by pre-transplantation variables. Outcomes between these two groups were then compared; once using the entire cohort, and once using the propensity score-matched patients. Survival was compared by Kaplan-Meier curve and log-rank tests. Results There were 26 patients below 70 years old that underwent concomitant CABG with lung transplantation. 25 of the 26 patients that underwent concomitant CABG were 1:1 propensity score-matched with 25 of the 410 patients that did not undergo concomitant CABG. There was no statistically significant difference in survival outcomes between patients less than 70 that underwent concomitant CABG and patients less than 70 that did not undergo concomitant CABG (p=0.24). When analyzing the two groups after propensity score matching, there was still no statistically significant difference in survival outcomes (p=0.51).Overall survival for patients less than 70 that underwent concomitant CABG was 100% at 1 year, and 72% at 3 years. Survival for patients that did not undergo concomitant CABG was 87% at 1 year, and 72% at 3 years. Conclusion Patients below 70 that underwent concomitant CABG with lung transplantation showed no significant difference in survival outcomes when compared to patients less than 70 that did not undergo concomitant CABG. Considering this data, patients less than 70 with CAD would be reasonable candidates for concomitant CABG with lung transplantation in selected cases.

Purpose The number of elderly patients requiring a lung transplantation (LTx) continues to grow. However, there are concerns that the age distribution of LTx recipients may be unbalanced, at a detriment to elderly patients. In order to assess the relationship between LTx and recipient age, we investigated the survival outcomes of elderly primary single and double LTx patients through analysis of the UNOS database. Methods We analyzed the UNOS database (1987-2014), investigating single and double LTx recipients based on three separate age groups (≤69, 70-74, and ≥75 years old). Using variables such as age, gender, ethnicity, BMI, length of stay (LOS), ECMO, inhaled NO usage, blood group, and procedure type, the three groups were compared for any significance (p=0.05). Survival outcomes were compared between the groups (STATA Inc.) and data were presented as mean±standard deviation. Results During 1987 to 2014, 27,980 patients received LTx (n= 16,015 double LTx, and n=11,888 single LTx). Out of total LTx patients, 27,076 patients were ≤69, 729 patients were 70-74, and 98 patients were ≥75 years old. Demographic data showed 54% male, 86% white, 7% black, 5% Latino, and 2% other. Recipient mean age was 55±15 years, with BMI- 24±4 kg/m2, median LOS was 15 days, and blood groups: O-45%, A-40%, B-11%, AB-4%. UNOS showed lower data on ECMO-1% and inhaled NO-0.21% usage. Log-rank test for equality of survival demonstrated significance based on age for patients who received single and double LTx (p Conclusion Survival outcome of single LTx patients did not show any significant statistical difference when performed in elderly patients above 70 years of age. When double LTx were performed, younger patients below 69 years of age seemed to do better in survival compared to elderly patients above 70 years of age. The beneficial survival outcome for single LTx patients extends to an older age than double LTx patients.

Purpose There are controversies regarding which side of the lungs, under-perfused versus over-perfused to be replaced when performing single lung transplantation (LTx). Theoretically, under-perfused lung appears to be better replaced rather than over-perfused lung; however, occasionally over-perfused lung is chosen due to limited organ availability, size discrepancy between the sides, or anatomical complexity, and this is recognized as ‘side-mismatching’ in single LTx. This study aims at evaluating the impact of side-mismatching on transplant outcomes. Methods Graft side-mismatching was defined with a prospectively designed formula using baseline quantitative lung perfusion scan data, and the patients who underwent single LTx between January 2016 and June 2018 were stratified as either side-matched or side-mismatched. A retrospective review of the LTx database was used to obtain short- and mid-term outcomes as well as complications for those patients. Results Two hundred eighteen patients received single LTx between January 2016 and June 2018. Out of these, there were a total of 18 patients had a side-mismatched graft while those with a side-matched graft over the same time period were used as controls. There were no significant differences between the groups in their patients’ characteristics except more patients with age above 70 years old and less patients with secondary pulmonary hypertension noted in the side-mismatched group. While the size-mismatched group consisted of more patients who underwent right single than left single LTx and required more intraoperative cardiopulmonary support (25% vs. 8.2%, p Conclusion Our data suggest that there is no evident increased risk or compromised post-transplant outcomes in performing side-mismatched single LTx when appropriate lung graft as well as intraoperative cardiopulmonary support is chosen. This strategy could optimize organ utilization increasing effective organ supply and decreasing waitlist mortality. In addition, this may contribute to avoiding the surgical or anatomical complexity leading to improved transplant outcomes.

Purpose The numbers of lung transplantation (LTx) recipients are gradually increasing worldwide. That leads to the subsequent question whether offering a redo-LTx is a viable option in some of those patients, especially the older patients, who were once transplanted. We investigated the survival outcome of single or double redo-LTx in both younger and elderly recipients analyzing the UNOS database. Methods Patients receiving single or double redo-LTx (n=1092; UNOS data from 1987-2014) were divided into three different groups based on recipient age - ≤69, 70-74, and ≥75 years old. Survival outcome was compared among the three groups using Kaplan-Meier Curve. Variables such as age, gender, ethnicity, BMI, length of stay (LOS), ECMO and inhaled NO usage, blood groups and types of procedures were compared for significance (p Results 498 had single and 594 had lung redo-LTx. 1069 patients were ≤69, 20 patients were 70-74, and 3 patients were over ≥75 years old. Demographic data showed 52% male, 87% white, 6% black, 5% Latino, and 2% others. Patients had BMI- 24 ± 5 kg/m2, median LOS 15 days, and blood groups: O-46%, A-40%, B-10%, AB-4%. Although UNOS data showed ECMO-4% and inhaled NO-1.3% usage, many data were missing from UNOS database for ECMO and inhaled NO. Log-rank test for equality of survival between the three groups showed no difference in survival for single redo-LTx (p=0.89), but demonstrated significance between the age cohorts for double redo-LTx (p=0.004). There was no significant difference in individuals receiving single redo-LTx based on age: ≤69 vs. 70-74 years old (p=0.63), ≤69 vs. ≥ 75 years old (p=0.94), 70-74 vs. ≥75 years old (p=0.91). Conclusion Single lung redo-LTx had no survival difference in different age groups compared to double lung redo-LTx. Older patients had more single lung redo-LTx than younger patients. Single lung redo-LTx data whether contralateral side or the same side lung redo-LTx was performed, were missing in UNOS database.