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The COVID pandemic has evolved as the SARS-2 Coronavirus (CoV-2) mutated into unique variants of concern (VOC). The clinical approach to COVID has evolved as new therapeutics have become available. Previous reports demonstrate differences in patient outcomes based on VOC, however outcomes in a lung transplant population have not been described. Our lung transplant program follows over 300 transplant recipients. Relevant information including date of first positive test, hospital admission, monoclonal antibody (mAb) or oral anti-viral treatment, CoV-2 vaccination history, tixagevimab/cilgavimab (T/C) and COVID attributed mortality have been tracked for quality improvement purposes. Outcomes were stratified by predominant US VOC at time of positive testing: wild strain 02/2020-02/2021, alpha strain 02/2021-05/2021, delta strain 06/2021-12/2021, omicron strain 01/2022- 09/25/2022. From 03/20/2020 through 09/25/2022, 142 recipients were diagnosed with COVID 152 times, including 9 recipients infected twice and 1 recipient infected 3 times. Most infected recipients tested positive with CoV-2 during the omicron wave. All recurrent infections occurred during the omicron wave. 8 deaths (5.6%) were attributed to COVID: 6 due to COVID respiratory failure, 1 stroke and 1 new restrictive-chronic lung allograft dysfunction. Therapies directed against CoV-2 were more likely administered in delta and omicron waves. Recipients were more likely to require hospital admission in wild type and alpha waves of CoV-2. Most deaths occurred in the wild type and delta waves. Deceased recipients, and those requiring hospital admission received less vaccinations and were less likely to have received T/C. (Table) This analysis shows changing trends in management and outcomes over the COVID pandemic. Future research should focus on transplant specific outcomes, including post-infection changes in allograft function and risk of developing chronic lung allograft dysfunction based on likely infecting VOC. [ABSTRACT FROM AUTHOR]