Purpose: Lung transplantation is a potentially lifesaving treatment for severe COVID-19 acute respiratory distress syndrome (ARDS), when optimized medical treatment fails to accomplish lung recovery. However, since the long-term outcomes remain unknown, concerns related to the use of lung transplantation in critically ill COVID-19 patients persist. In the current study, we evaluated consecutive patients that underwent lung transplantation for severe COVID-19 ARDS at our center and compared their post-transplant outcomes with those undergoing transplantation for non-COVID-19 pathology during the concurrent study period.MethodsAll consecutive patients undergoing lung transplantation between January 2020 to May 2021 were included. The study included two cohorts of patients that underwent transplantation for non-COVID-19 disease (nC19) or refractory COVID-19 ARDS (C19). For additional analysis, we included consecutive patients with severe COVID-19 that required veno-venous extracorporeal membrane oxygenation (ECMO).ResultsWe found that post-procedure complications and length of stay were significantly greater compared to transplants performed for non-COVID-19 lung diseases during the concurrent study period. Following transplant the COVID-19 cohort demonstrated a more rapid improvement in Karnofsky performance status. At one year, all recipients in COVID-19 cohort were alive with post-transplant survival no different than institutional non-COVID-19 recipients. Furthermore, when compared to propensity-matched recipients from SRTR, post-transplant survival of institutional COVID-19 ARDS patients was non-inferior. There was progressive reduction in the probability of separation from extracorporeal membrane oxygenation (ECMO) with time and ECMO support greater than 30 days was associated with a significantly greater risk of death in patients with COVID-19 ARDS. In those who remained unweanable from ECMO after 30 days, lung transplant was an independent predictor of survival.ConclusionWe conclude that lung transplantation in selected patients with severe COVID-19 ARDS who remain unweanable from extracorporeal life support can result in post-transplant outcomes comparable to recipients with chronic end-stage lung diseases and non-COVID-19 ARDS.