Single LTx Research Articles

Lung transplantation following controlled hypothermic storage with a portable lung preservation device: first multicenter European experience.

Compared with traditional static ice storage, controlled hypothermic storage (CHS) at 4-10°C may attenuate cold-induced lung injury between procurement and implantation. In this study, we describe the first European lung transplant (LTx) experience with a portable CHS device. A prospective observational study was conducted of all consecutively performed LTx following CHS (11 November 2022 and 31 January 2024) at two European high-volume centers. The LUNGguard device was used for CHS. The preservation details, total ischemic time, and early postoperative outcomes are described. The data are presented as median (range: minimum-maximum) values. A total of 36 patients underwent LTx (i.e., 33 bilateral, 2 single LTx, and 1 lobar). The median age was 61 (15-68) years; 58% of the patients were male; 28% of the transplantations had high-urgency status; and 22% were indicated as donation after circulatory death. In 47% of the patients, extracorporeal membrane oxygenation (ECMO) was used for perioperative support. The indications for using the CHS device were overnight bridging (n = 26), remote procurement (n = 4), rescue allocation (n = 2), logistics (n = 2), feasibility (n = 1), and extended-criteria donor (n = 1). The CHS temperature was 6.5°C (3.7°C-9.3°C). The preservation times were 11 h 18 (2 h 42-17 h 9) and 13 h 40 (4 h 5-19 h 36) for the first and second implanted lungs, respectively, whereas the total ischemic times were 13 h 38 (4 h 51-19 h 44) and 15 h 41 (5 h 54-22 h 48), respectively. The primary graft dysfunction grade 3 (PGD3) incidence rates were 33.3% within 72 h and 2.8% at 72 h. Intensive care unit stay was 8 (4-62) days, and the hospital stay was 28 (13-87) days. At the last follow-up [139 (7-446) days], three patients were still hospitalized. One patient died on postoperative day 7 due to ECMO failure. In-hospital Clavien-Dindo complications of 3b were observed in six (17%) patients, and 4a in seven (19%). CHS seems safe and feasible despite the high-risk recipient and donor profiles, as well as extended preservation times. PGD3 at 72 h was observed in 2.8% of the patients. This technology could postpone LTx to daytime working hours. Larger cohorts and longer-term outcomes are required to confirm these observations.

Single Lung Transplantation After Open Window Thoracotomy for Empyema: A Case Report

A 41-year-old woman with lymphangioleiomyomatosis developed a bronchial anastomotic stenosis after left single lung transplantation (LTx). A part of the hyperinflated right native lung was excised in an attempt to remedy the left lung compression, which appeared to affect the bronchial anastomotic stenosis and ventilation/perfusion mismatch. However, a persistent air leak after the surgery caused empyema and an open window thoracotomy (OWT) was performed. She remained oxygen-dependent and was relisted for lung transplantation. A right single LTx on the side of OWT was performed, achieving long-term survival with no activity limitations for the patient. We report here the first successful LTx after OWT for empyema.

Lung Transplantation Outcomes in Recipients Aged 70 Years or Older and the Impact of Center Volume.

To evaluate trends and outcomes of lung transplants (LTx) in recipients ≥ 70 years. We performed a retrospective analysis of the UNOS database identifying all patients undergoing LTx (May 2005-December 2022). Baseline characteristics and postoperative outcomes were compared by age (<70 years, ≥70 years) and center volume. Kaplan-Meier analyses were performed with pairwise comparisons between subgroups. 34,957 patients underwent LTx, of which 3236 (9.3%) were ≥70 years. The rate of LTx in recipients ≥ 70 has increased over time, particularly in low-volume centers (LVCs); consequently, high-volume centers (HVCs) and LVCs perform similar rates of LTx for recipients ≥ 70. Recipients ≥ 70 had higher rates of receiving from donor after circulatory death lungs and of extended donor criteria. Recipients ≥ 70 were more likely to die of cardiovascular diseases or malignancy, while recipients < 70 of chronic primary graft failure. Survival time was shorter for recipients ≥ 70 compared to recipients < 70 old (hazard ratio (HR): 1.36, 95% confidence interval (CI): 1.28-1.44, p < 0.001). HVCs were associated with a survival advantage in recipients < 70 (HR: 0.91, 95% CI: 0.88-0.94, p < 0.001); however, in recipients ≥ 70, survival was similar between HVCs and LVCs (HR: 1.11, 95% CI: 0.99-1.25, p < 0.08). HVCs were more likely to perform a bilateral LTx (BLT) for obstructive lung diseases compared to LVCs, but there was no difference in BLT and single LTx likelihood for restrictive lung diseases. Careful consideration is needed for recipient ≥ 70 selection, donor assessment, and post-transplant care to improve outcomes. Further research should explore strategies that advance perioperative care in centers with low long-term survival for recipients ≥ 70.

Trends and Outcomes in Lung Transplantation in Patients with and without Idiopathic Pulmonary Fibrosis in Spain during the Period 2016-2020.

(1) Background: This paper aims to assess temporal trends (2016-2020) in incidence, patient's characteristics, complications, length of hospital stay (LOHS) and in-hospital mortality (IHM) among patients with and without idiopathic pulmonary fibrosis (IPF) undergoing lung transplantation (LTx). We also analyse the effect of the COVID-19 pandemic on LTx in these populations. (2) Methods: A retrospective, population-based observational study was conducted using the Spanish National Hospital Discharge Database. Multivariable adjustment was conducted with logistic regression to analyse the IHM. (3) Results: We identified 1777 admissions for LTx during the study period, of which 573 (32.2%) were performed in patients with IPF. The number of hospital admissions for LTx rose from 2016 to 2020, both in patients with and without IPF, but a marked reduction was observed from year 2019 to year 2020. Over time, the proportion of single LTx decreased and bilateral LTx increased significantly in both groups. The incidence of LTx complications increased significantly over time along with the increase in the incidence of IPF. No significant differences in the incidence of complications or in the IHM between patients with and without IPF were found. Suffering any complication of the LTx and pulmonary hypertension were conditions positively associated with IHM in patients with and without IPF. The IHM remained stable from 2016 to 2020 in both study populations and was not affected by the COVID pandemic. (4) Conclusions: Patients with IPF account for almost a third of all lung transplants. The number of LTx increased over time in patients with and without IPF, but a marked reduction was observed from 2019 to 2020. Although the proportion of LTx complications increased significantly over time in both groups, the IHM did not change. IPF was not associated with increased complications or IHM after LTx.

Lung transplant survival with past and concomitant cardiac revascularization

Coronary artery disease is common among lung transplant (LTx) candidates and has historically been viewed as a contraindication to the procedure. Survival outcomes of lung transplant recipients with concomitant coronary artery disease who had prior or perioperative revascularization remain a topic of conversation. A retrospective analysis of all single and double lung transplant patients from Feb, 2012 to Aug, 2021 at a single center was performed (n=880). Patients were split into 4 groups: (1) those who received a preoperative percutaneous coronary intervention, (2) those who received preoperative coronary artery bypass grafting, (3) those who received coronary artery bypass grafting during transplantation, and (4) those who had lung transplantation without revascularization. Groups were compared for demographics, surgical procedure, and survival outcomes using STATA Inc. A p value<0.05 was considered significant. Most patients receiving LTx were male and white. Pump type (p = 0.810), total ischemic time (p= 0.994), warm ischemic time (p = 0.479), length of stay (p =0.751), and lung allocation score (p = 0.332) were not significantly different between the four groups. The no revascularization group was younger than the other groups (p<0.01). The diagnosis of Idiopathic Pulmonary Fibrosis was predominant in all groups except the no revascularization group. The pre-coronary artery bypass grafting group had a higher portion of single LTx procedures (p = 0.014). Kaplan-Meier analysis showed no significantly different survival rates after post-LTx between the groups (p = 0.471). Cox Regression analysis showed diagnosis significantly impacted survival rates (p 0.009). 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 procedures.

Same-teams versus different-teams for long distance lung procurement: A cost analysis.

In an era of broader lung sharing, different-team transplantation (DT, procuring team from nonrecipient center) may streamline procurement logistics; however, safety and cost implications of DT remain unclear. To understand whether DT represents a safe means to reduce lung transplant (LTx) costs, we compared posttransplant outcomes and lung procurement and index hospitalization costs among matched DT and same-team transplantation (ST, procuring team from recipient center) cohorts at a single, high-volume institution. We hypothesized that DT reduces costs without compromising outcomes after LTx. Patients who underwent DT between January 2016 to May 2020 were included. A cohort of patients who underwent ST was matched 1:3 (nearest neighbor) based on recipient age, disease group, lung allocation score, history of previous LTx, and bilateral versus single LTx. Posttransplant outcomes and costs were compared between groups. In total, 23 DT and 69 matched ST recipients were included. Perioperative outcomes and posttransplant survival were similar between groups. Compared with ST, DT was associated with similar lung procurement and index hospitalization costs (DT vs ST, procurement: median $65,991 vs $58,847, P=.16; index hospitalization: median $294,346 vs $322,189, P=.7). On average, procurement costs increased $3263 less per 100 nautical miles for DT versus ST; DT offered cost-savings when travel distances exceeded approximately 363 nautical miles. At our institution, DT and ST were associated with similar post-LTx outcomes; DT offered cost-savings with increasing procurement travel distance. These findings suggest that DT may mitigate logistical and financial burdens of lung procurement; however, further investigation in a multi-institutional cohort is warranted.

Cytomegalovirus Infection Is Associated with Development of Chronic Lung Allograft Dysfunction

BackgroundCytomegalovirus (CMV) is the major and most common opportunistic infection complicating lung transplant (LTX). The aim of this study was to analyse the epidemiological aspects of CMV infection in lung transplant patients subject to a pre-emptive anti-CMV approach and to study the impact of this infection on lung transplant outcome, in terms of onset of chronic lung allograft dysfunction (CLAD).MethodsThis single-centre retrospective study enrolled 87 LTX patients (median age 55.81 years; 41 females, 23 single LTX, 64 bilateral LTX). All patients were managed with a pre-emptive anti-CMV approach. The incidences of the first episode of CMV infection, 1, 3, 6 and 12 months after LTX, were 12.64%, 44.26%, 50.77% and 56.14%. A median interval of 41 days elapsed between LTX and the first episode of CMV infection. The median blood load of CMV-DNA at diagnosis was 20,385 cp/ml; in 67.64% of cases, it was also the peak value. Patients who had at least one episode had shorter CLAD-free survival. Patients who had three or more episodes of CMV infection had the worst outcome.ResultsCMV infection was confirmed to be a common event in lung transplant patients, particularly in the first three months after transplant. It had a negative impact on transplant outcome, being a major risk factor for CLAD. The hypothesis that lower viral replication thresholds may increase the risk of CLAD is interesting and deserves further investigation.

Impact of Lung Function Decline on Mortality in Lung Transplant Recipients: Long-Term Results From the L-CsA-i Study for the Prevention of Bronchiolitis Obliterans Syndrome.

BackgroundChronic lung allograft dysfunction (CLAD) is defined by a progressive loss of FEV1 and is associated with premature mortality. The aim of this study was to investigate the direct association between FEV1 decline and risk of mortality in patients after lung transplantation (LTx).Methods10-year follow up data from lung transplant recipients participating in randomized placebo-controlled clinical trial investigating the role of liposomal Cyclosporine A for inhalation (L-CsA-i) in the prevention of bronchiolitis obliterans syndrome (NCT01334892) was used. The association between the course of FEV1 over time and the risk of mortality was assessed using joint modeling and Cox regression analysis.ResultsA total of 130 patients were included. Predictors of FEV1 decline were a higher absolute FEV1 at baseline and male sex. The joint model analysis indicated a significant association of change of FEV1 and risk of mortality (p < 0.001), with a predicted 3.4% increase in mortality risk for each 1% decline in FEV1. Significant predictors of a progressive phenotype were single LTx and treatment with placebo (as opposed to L-CsA-i). At the end of follow-up, 82 patients (63.1%) were still alive. Cox regression analyses for mortality identified only single LTx as a predictor of higher risk.ConclusionBased on our observation of a close association between FEV1 and mortality over a period of 10 years we suggest FEV1 as a valid predictor of mortality and a suitable surrogate endpoint in the investigation of early interventions.

Chronic lung allograft dysfunction and restrictive allograft syndrome: are phenotypes robust and helpful?

New chronic lung allograft dysfunction (CLAD) consensus documents were published in 2019, defining four phenotypes; bronchiolitis obliterans syndrome, restrictive allograft syndrome, mixed and undefined. Clearly, validation of these guidelines in a real life cohort is critical. Indeed, validation has been performed recently, both after bilateral lung transplantation (LTx) and after single LTx illustrating that precise phenotyping based on pulmonary function alone can be difficult. Undertaking regular chest computed tomography scanning does appear very helpful in establishing the prognosis of the patients with CLAD. Pulmonary function changes may not always identify the exact phenotype of CLAD and we provide further evidence for the important role of chest imaging at diagnosis and during the follow-up of patients with CLAD.

The Impact of HLA Mismatch Level in COPD Lung Transplantation Patients

<h3>Purpose</h3> Lack of research exists on Human Leukocyte Antigen (HLA) Mismatch on lung transplantation (LTx) survival outcome, particularly in Chronic Obstructive Pulmonary Disease (COPD) patients. This study analyzes how HLA mismatch affects survival outcome in LTx COPD patients since lung allocation score (LAS) implementation. <h3>Methods</h3> We retrospectively analyzed 41,675 LTx patients from The United Network for Organ Sharing (UNOS) database and extracted 5,411 COPD patients (2005-2020) since LAS implementation. Redo LTx's were excluded, and remaining patients were divided into two groups, HLA mismatch level from 0-2 and HLA mismatch level from 3-6. These groups were further divided by having had a single LTx (SLT) or double LTx (DLT). Kaplan-Meier survival analysis and log-rank tests were done to compare the two HLA mismatch level groups among all COPD patients and between each transplant type using JMP Pro 16, SAS Inc. A p-value <0.05 was considered statistically significant. <h3>Results</h3> Of the LTx COPD patients in the HLA mismatch level 0-2 group (n=236), 82 had a SLT and 154 had a DLT. In the HLA mismatch level ≥ 3 group (n=5175), 1711 had a SLT and 3464 had a DLT. Using Kaplan-Meier curves, there was no significant difference in survival outcome (p=.16) between the two HLA mismatch level groups among all COPD LTx patients. Survival rates for the HLA mismatch 0-2 group at 30 days, 5-years and 10-years were 98%, 64% and 34% respectively vs. 97%, 58% and 29% for the HLA mismatch ≥ 3 group. However, when comparing the two HLA mismatch level groups between patients having a SLT or DLT using Kaplan-Meier curves, a significant difference (p<.0001) was found (Figure 1) in the HLA mismatch group ≥ 3 which showed DLT providing improved survival outcomes compared to SLT. <h3>Conclusion</h3> There remains unclear evidence regarding HLA mismatch level and its impact on LTx survival outcome. Since LAS implementation, the results of this study suggest that DLT provides better survival outcomes even with a HLA mismatch level ≥ 3 for lung transplantation patients with COPD.

Donor to Recipient Transmission of Bacterial Pathogens in Relation to Cold Ischemic Time in Lung Transplantation

<h3>Purpose</h3> To evaluate the effect of cold ischemic time (CIT) on donor pathogen transmission after lung transplantation (LTx). <h3>Methods</h3> We reviewed data of 59 patients from 2011 to 2018 and analyzed the cultures results of donor bronchial aspirate (DBA), graft endobronchial bacterial swab (GEBS), recipient bacterial status before transplantation (RBT) and postoperative recipient bronchial aspirate (RBA) in relation to donor hospital length of stay (LOS), CIT and to recipient intubation time, Intensive Care Unit (ICU) and hospital LOS, perioperative and infection related deaths. The groups were compared using Mann-Withney U test and Fisher's exact test, death risk was analyzed as hazard ratio with 95% CI. <h3>Results</h3> Single LTx was in 17 cases, bilateral LTx in 42. First/only lung CIT1 was 403±107 min, second lung CIT2 - 541±114 min (the data are shown as mean ± Standard Deviation) . Cultures were positive in 42,2% DBA, 83,1% GEBS, 79,7% RTB, 33,9% RBA. Longer donor hospital LOS (132±52 v.100±79 hrs) was associated with isolation of DBA Gram-negative bacteria (n=16), especially <i>A. baumannii</i>). Longer CIT2 (600±109 v. 518±108 min) was related to Gram-positive bacteria other than MSSA in GEBS and it caused recipient's longer ICU LOS (21±18 v. 10±13 days). Longer CIT1 (476±113 v. 388±100 min) and CIT2 (613±91 v. 522±113 min) was associated with growing the new pathogens in RBA. Longer CIT1 (440±102 v. 374±102 min) and CIT2 (584±101 v. 498±111 min) caused prolonged recipient intubation time above 3 days (n=26) and CIT2 (607±93 v. 521±113 min) was related to recipient perioperative death (n=10), but these two factors were not affected by positive DBA, GEBS nor RBA.. Recipient infection deaths (n=4), recipient ICU LOS above 7 days (n=21) and hospital LOS above 30 days (n=30) were not related to DBA, GEBS nor RBA. Positive DBA, GEBS and RBA did not increase recipient death risk - HR 0,690; 0,348 and 1,369 respectively. <h3>Conclusion</h3> The cultures GEBS brought more information than DBA. Longer CIT increased Gram-positive bacteria load other than MSSA in GEBS<i>.</i> Donor hospital LOS was correlated with Gram-negative bacteria colonization. Positive cultures of DBA, GEBS, RBA did not affect recipient intubation time, ICU and hospital LOS, perioperative or infection related deaths.

Single Lung Transplantation for Pulmonary Fibrosis Secondary to COVID-19

IntroductionAs of April 2021, 78 lung transplants (LTx) were performed for a diagnosis of COVID-19: 50 for COVID-19 ARDS and 28 for pulmonary fibrosis. Bilateral LTx has been recommended as many patients develop significant pulmonary hypertension. Additionally, native lung explants may include cavitary areas of pneumonia, which could serve as a nidus for infection. Single LTx (SLTx) can be considered in patients who have chronic pulmonary fibrosis secondary to COVID-19 with a short window to receive a transplant, or who would otherwise be considered for a single lung. There have been no published cases of a single lung transplant for COVID-19 pulmonary fibrosis. We present a case of a patient with pulmonary fibrosis from COVID-19 who underwent SLTx.Case ReportA 70yo male with O+ blood type was hospitalized 8/2020 to 10/2020 with COVID-19 pneumonia, treated with Remdesivir and Tocilizumab. He had hypoxia but never required intubation. His course was complicated by bilateral pneumothoraces requiring chest tubes. He developed pulmonary fibrosis requiring 6 L of oxygen at rest. CT scan of his chest showed multifocal, peripheral prominent ground glass opacities and interlobal septal thickening with traction bronchiectasis. Ventilation-perfusion scan demonstrated 22% perfusion to the left lung and 78% to the right lung. Right heart catheterization showed pulmonary artery pressures of 36/12 mmHg. His pulmonary function test was suggestive of restrictive disease (FEV 0.81 L [30%], FVC 0.96 L [27%], and FEV1/FVC 85%) that had worsened over time. He was presented at multidisciplinary review board with recommendation to list for left SLTx, which was activated August 2021. The patient was admitted in September 2021 and underwent left single lung transplant via left anterolateral thoracotomy, off cardiopulmonary bypass. Total ischemia time was 3:54. Explant pathology showed end stage pulmonary fibrosis. The patient was extubated on postoperative day 1 with an uneventful postoperative course. He was discharged to skilled nursing facility on postoperative day 26 for rehabilitation.SummarySLTxp is safe and feasible for COVID-19 related pulmonary fibrosis in well-selected patients who have a short window to receive a transplant.

CFTR Modulators and Lung Transplantation: Factors to Consider - A UK Transplant Centre Experience

<h3>Purpose</h3> Cystic fibrosis transmembrane conductance regulator (CFTR) modulators are drugs that act on the defective CFTR protein in people with cystic fibrosis (pwCF), resulting in improved CFTR protein function and thus improved CF symptoms. Evidence is increasing of their positive impact on extra-pulmonary features of CF, which remains problematic in pwCF post-lung transplantation (LTx). Elexacaftor/tezacaftor/ivacaftor (ele/tez/iva) was licensed in the UK in August 2020. It has been debated since if ele/tez/iva has a role post-LTx for ongoing non-pulmonary CF symptoms. We aim to highlight the practical issues faced when considering this drug in the post-LTx CF population in a single large UK LTx unit. <h3>Methods</h3> Retrospective analysis of electronic records of pwCF post-LTx with ongoing extra-pulmonary manifestations considered for initiation of ele/tez/iva August 2020-2021, including demographics, potential benefits, contraindications and outcomes. <h3>Results</h3> 5 pwCF with LTx have been discussed with their CF physicians to consider initiating ele/tez/iva (some had more than one problem):- sinus (n = 2); bowels (n = 2); weight (n = 2); other (n = 2). All were at least 12 months post-LTx (median 42 months; range 21-191 months). Discussions were initiated by the patient in 1 case, the CF team in 2, and transplant team in 2. 3 were not initiated - 1 due to potential side effects on mental health and 2 were contraindicated with deranged liver tests and ongoing bowel symptoms. 2 were initiated on ele/tez/iva. Of these, one is on tacrolimus, needed no immunosuppression adjustment, but stopped due to drop in FEV1 (CT and biopsy negative for features of rejection) which recovered. The other is on sirolimus, needed significant reduction in immunosuppression (9mg to 4mg) and remains on ele/tez/iva. <h3>Conclusion</h3> Extra-pulmonary manifestations of CF are varied and continue post-LTx. With increasing evidence supporting using CFTR modulators to manage extra-pulmonary symptoms, it is important to establish the role these drugs can have in the post-LTx CF population, but also the potential risks. Our experience so far shows mixed results and that discussion between CF and transplant physicians, with patient involvement is vital to ensure correct decisions are taken. Randomised controlled trials are needed to ensure modulator use in pwCF post-LTx is supported by robust evidence.

Bronchial Suturing Techniques After Lung Transplant: A Single Surgeon Analysis

<h3>Purpose</h3> In lung transplantation (LTx) postoperative airway complications can increase morbidity and mortality. Current literature offers little analysis examining a single surgeon's work. We assessed postoperative bronchial complication rates, treatments, and survival outcomes in LTx performed by a single surgeon and stratified data by suturing technique. <h3>Methods</h3> A single surgeon's LTx (n=444) were analyzed from 901 total LTx done between Feb 2012- March 2021. Continuous suturing (CS) and intermittent suturing (IS) techniques were compared. CS technique was done with 3/0 polypropylene suture on an SH needle. IS is used on the membranous portion of the anastomosis and multiple interrupted 3/0 polypropylene sutures are used for the cartilaginous portion. Demographic and clinical data, post op bronchial complications, and their interventions were compared and categorized. Survival was compared with Kaplan-Meier curves and log-rank tests. Cox regression analysis was run using all variables to assess impact on survival. P values <0.05 were considered significant. <h3>Results</h3> Of 444 patients in this single surgeon study, 259 received IS and 185 received CS. ECMO was utilized in 19 CS patients vs 18 IS patients IS (p = 0.371). There was no significant difference in post-transplant complication rates (p = 0.629). The most common complications were stenosis (CS14; IS-19), ischemia (CS 0; IS-7), and stenosis + malacia + dehiscence (CS 4; IS9). Treatment for bronchial complications was varied, including dilation and stent placement when indicated for the complications of both CS and IS. Kaplan-Meier curve showed no difference in survival outcomes between groups (p = 0.562). Cox regression analysis with all variables showed that the type of induction (Hz 1.48; p=0.01) and CPB (Hz 1.44; p=0.024) had a significant effect on survival. <h3>Conclusion</h3> Analysis of suturing techniques in a single surgeon at a single center showed comparable survival outcomes, bronchial complication rates, and follow up treatments between IS and CS techniques.

Bronchial Complications and Survival Outcomes in Post-Lung Transplant

<h3>Purpose</h3> This study contrasts the current standard practice of continuous suturing to interrupted suturing during lung transplantation (LTx). We compared survival outcomes between groups, and further categorized the differences in the rate, type, and treatment of bronchial complications. <h3>Methods</h3> There were 889 LTx at our high-volume single center from Feb2012 to Jun2021. Continuous suturing was executed using 3/0 polypropylene suture on an SH needle. Interrupted implemented the same technique for the membranous portion of the anastomosis, and multiple interrupted 3/0 polypropylene sutures for the cartilaginous portion. Kaplan-Meier curves and log-rank tests compared survival, and Cox regression analysis examined impact on survival. Clinical parameters and demographics were compared, with p values <0.05 considered significant. <h3>Results</h3> Of 889 patients, 548 received continuous suturing while 341 received interrupted suturing. Demographics and clinical parameters between groups were: age (p = 0.029), gender (p = 0.9), race (p = 0.63), etiology (p = 0.261), lung allocation score (p = 0.25), BMI (p = 0.049), single versus double LTx (p < 0.0001). Bronchial complications occurred at similar rates (p = 0.38), as did types of complications (ischemia/necrosis, dehiscence, stenosis, malacia) except for dehiscence (4.5% continuous, 0.7% interrupted). ECMO was utilized in 54 vs 28 patients (continuous vs. interrupted; p = 0.12). Complications were treated similarly (p = 0.69) with dilation + stent being the most common treatment. Kaplan-Meier survival curve showed no significant difference in survival (p = 0.177). Cox regression analysis showed no difference between techniques, with bronchial complications, ECMO usage, and diagnosis having a statistically significant effect on survival. <h3>Conclusion</h3> Our study found similar survival outcomes, bronchial complication rates, and complication treatments between techniques, demonstrating comparable outcomes for both techniques.

Long-Term Weaning of Mechanical Ventilation After Lung Transplantation: Patient Characteristics and Impact on Survival

<h3>Purpose</h3> Following lung transplantation (LTx), some recipients may require a prolonged postoperative course including long-term weaning of mechanical ventilation, raising concerns regarding transplant benefit. The aim of this study was to characterize this subgroup of patients, identify risk factors of prolonged mechanical ventilation (PMV), and determine impact on survival. <h3>Methods</h3> We retrospectively reviewed all adult LTx procedures performed at our center between January 2008 and January 2019 (n=1138). Logistic regression analysis of baseline characteristics and peri-operative variables was utilized to identify risk factors for PMV. The subgroup with PMV > 60 days was then compared to a random sample of patients of equal size with short MV (< 48 hr). <h3>Results</h3> Fifty-eight patients (5%) underwent PMV > 60 days (median 99.5, IQR 71-152 days). Independent risk factors for PMV > 60 days were bridging on MV, double (versus single) LTx, concomitant cardiac procedure, re-exploration for bleeding, and primary graft dysfunction higher grades. At time of LTx listing, the group with PMV > 60 days had higher lung allocation score (72 [44-89] vs 40 [35-48], p < .01), greater chest wall soft tissue to pectoralis muscle thickness ratio (3 ± 1 vs 2 ± 1, p = .02), lower 6-minute walk test distance (873 [680-1058] vs 1003 [821-1183], p = .03), increased bridging on MV (72% vs 53%, p = .03) or ECMO (29% vs 0%, p < .01), compared to patients with short MV (< 48 hr). The group with PMV > 60 days underwent more double LTx (93% vs 48%, p < .01), cardiopulmonary bypass utilization (93% vs 45%, p < .01), concomitant cardiac procedures (29% vs 5%, p < .01), re-exploration for bleeding (36% vs 3%, p < .01), delayed chest closure (52% vs 2%, p < .01), post-LTx ECMO (24% vs 0%, p < .01), and had higher primary graft dysfunction grade 3 (48% vs 2%, p < .01). Additionally, patients with PMV > 60 days had higher hospital mortality (15% vs 3%, p = 0.02) and lower 1-year survival (59% vs 86%, p < .01); however, there was no difference in 3- or 5-year survival. <h3>Conclusion</h3> LTx recipients who undergo long-term weaning of MV have unique baseline characteristics prior to listing that influence the likelihood of a prolonged perioperative course and worse short-, but not long-, term survival. Understanding the specific predictors of PMV, and which are potentially modifiable, would contribute to optimal recipient selection.

Differential Response of Right Ventricular Contractility to Lung Ischemia-Reperfusion Injury: Large Animal Model to Study Sequential Single Lung Transplantation

<h3>Purpose</h3> Early outcome after lung transplantation (LTx) is often characterized by the presence of primary graft dysfunction (PGD). The exact role of the right ventricle (RV) in development of PGD and perioperative outcome is unknown. Firstly, increased afterload due to PGD might compromise RV function. Secondly, increased contractility and cardiac output (CO) of RV might contribute to pulmonary edema accumulation after reperfusion. We developed a unique large animal model to study RV behavior in a setting of pulmonary ischemia-reperfusion injury (IRI). <h3>Methods</h3> The left lung (LL) of a domestic pig in clamping group [CLA] was clamped (3h warm ischemia) and reperfused (3h) in situ (n=6). During the final hour of reperfusion, contralateral right lung (RL) was clamped to force RV CO to the injured LL. Control animals [CON] were fully instrumented (n=5) and followed for 6 hours. The RV function was monitored using a conductance catheter measuring pressure-volume (PV) loops. Lung injury was assessed by wet to dry (W/D) ratio and ex-vivo computed tomography (CT). Data was analyzed in time using 2-way ANOVA test or student T-test. <h3>Results</h3> Pulmonary vascular resistance (PVR) rose significantly at hour 6 in [CLA], reflecting an increase of afterload due to IRI and RL camping (<i>fig. A</i>). RV Contractility was stable in [CON]. In [CLA], it increased in 2 animals (<i>fig. D</i>) and 4 animals developed RV failure (<i>fig. B</i>). Lungs were injured as reflected by higher W/D ratio (<i>p=0.0019</i>) and parenchymal density on CT (<i>p=0.0089</i>) of [CLA] LL compared to [CON]. <h3>Conclusion</h3> RV response to increased afterload resulting from IRI occurs in a dichotomized way: with increased contractility or with failure. This occurs when the contralateral lung is clamped and mimics a specific intra-operative situation of sequential single LTx. Our model should be considered as an innovative platform to study the possible benefit of ECLS devices on RV function and PGD development after LTx.

Never Say Never: A 3D Anatomic Model Creates a Surgical Roadmap for Ultra-Complex Lung Transplant Recipient

<h3>Introduction</h3> Prior cardiac surgery, particularly coronary artery bypass graft (CABG) with a left internal mammary artery (LIMA), poses a technical challenge to lung transplant (LT). LT candidates with a history of CABG most often undergo a single LTx, limiting candidacy for those who require bilateral LTx (BLTx). Three-dimensional (3D) modeling may afford an opportunity for improved surgical planning when performing BLTx in recipients with multiple operative challenges. <h3>Case Report</h3> A 61-year-old man with a history of idiopathic pulmonary fibrosis, single vessel CABG (LIMA to left anterior descending artery), aortic valve replacement, and septal myomectomy was transferred to our center with hypoxemic respiratory failure requiring mechanical ventilation and veno-venous extracorporeal membrane oxygenation (VV-ECMO). Evaluation revealed a dilated right ventricle with reduced systolic function due to severe pulmonary hypertension (PH). The presence of PH and right ventricular dysfunction suggested a need for BLTx; however, we had concerns regarding the steric relationship of his patent LIMA to LAD graft. Traditionally, he would not be a candidate for BLTx based on these anatomic concerns and ongoing physiology. A 3D printed model of the patient's chest was developed as a novel means to plan the surgical approach. The donor's lungs were procured and placed on Organ Care System^TM to decrease ischemic time. The patient underwent bilateral anterolateral thoracotomies with sternal preservation. A left-sided dissection plane was created and, using the cues of the 3D model, the area where the anterior aspect of the left lung adhered to the mediastinum was identified and the lung was divided distal to and on both sides of the predicted location of the LIMA. In a planned fashion, the patient was transitioned from VV-ECMO to central CPB with cannulation of the ascending aorta through the right chest and conversion of ECMO cannulas into bicaval venous drainage. At the conclusion of the BLTx, the patient was decannulated and transferred to the ICU for ongoing care. He left the hospital a month after transplant and is doing well without supplementary oxygen as an outpatient. <h3>Summary</h3> Patient-specific 3D modeling may be used to help guide a safe and individualized surgical approach in complex patients with a prior history of CABG requiring a BLTx.

Extracorporeal Life Support (ECLS) in Sequential Single-Lung Transplantation: Single-Center Retrospective Analysis of ECLS-Related Complications

<h3>Purpose</h3> Use of extracorporeal life support (ECLS) in lung transplantation (LTx) is center dependent. Peri-operative use of ECLS in sequential single LTx (SSLTx) in our department is conservative to avoid specific ECLS-related complications. In this study we describe the incidence and nature of ECLS-related complications in our LTx experience. <h3>Methods</h3> All transplantations with peri-operative use of ECLS (2010-2020) were retrospectively analyzed. The demographics, the type of ECLS and its indication were described. All complications were divided within prior specified groups (<i>Fig 1, B</i>). <h3>Results</h3> Overall the use of ECLS was 22% (156/703 patients) in our patients (mean age of 52 (36-59)). In 84% (131/156) of the patients an arterial cannula was inserted. In 16% (25/156) only venous cannulation was performed. In 7% (11/156) cardiopulmonary bypass (CPB) was applied intra-operatively. Most common indications for LTx (<i>Fig 1, A, C</i>) was pulmonary fibrosis in 38% (60/156). Main indication for ECLS was intra-operative hemodynamic instability in 52% (81/156) (<i>Fig 1, A, D</i>). 16% (25/156) of patients were bridged to LTx on ECLS and 13% (20/156) required prolonged ECLS post-operatively. Thirty day mortality was 6% (9/156). The use of ECLS did not change over time, the overall incidence of patients with at least one complication was 67% (104/156), over the past years it increased from 56% to 78% (<i>Fig 1, A, B</i>). Most common complications were revision for hemothorax in 25% (39/156) and need for continuous renal replacement therapy (CRRT) in 19% (<i>Fig 1, A, E</i>). <h3>Conclusion</h3> In our center, we only use ECLS in 22% of our SSLTx population. However, when ECLS is applied, we report a relatively high number of post-operative complications. Based on our results, we need to focus our attention on kidney failure and strategies to manage coagulation. Center experiences are important but larger databases will be necessary to develop uniform approaches and reports on ECLS in LTx.

Prior and Perioperative Revascularization Impact on Survival in Lung Transplant Patients

<h3>Purpose</h3> Survival outcomes of lung transplant recipients with concomitant coronary artery disease who had prior or perioperative revascularization remains a topic of conversation. We hypothesized concomitant-CABG can be a safe and viable option during lung transplantation in a select group of patients. <h3>Methods</h3> A retrospective analysis of all single and double lung transplant patients from Feb-2012 to Aug-2021 (n=868) was performed. Patients were split into 4 groups: (1) those who received a preoperative percutaneous coronary intervention (n=58), (2) those who received pre-operative coronary artery bypass grafting (CABG) (n=39), (3) those who received concomitant CABG during transplantation (n=51), and (4) those who had lung transplantation without revascularization (n=720). Groups were compared for demographics, surgical procedure, and survival outcomes using STATA Inc. P-value <0.05 was considered significant. <h3>Results</h3> Throughout all groups, a majority of patients receiving LTx were males (p<0.01) and ethnically white (p<0.01). The no revascularization group was significantly younger than the other groups (p<0.01). The diagnosis of IPF constituted the largest portion of all groups except the no revascularization group (p<0.01). In terms of transplant type, the pre-CABG group had a higher portion of single LTx procedures (p=0.014). The antero-axillary thoracotamy approach was the most utilized approach in all groups except Con-CABG (p=0.014). Kaplan-Meier analysis showed that survival rates post-LTx were not significantly different between the groups (p=0.471). Cox Regression analysis showed diagnosis significantly impacted survival rates (p=0.009). <h3>Conclusion</h3> These results continue to suggest that preoperative or intraoperative revascularization did not affect survival outcomes in lung transplant patients. Select patients with coronary artery disease may benefit when intervened during lung transplant procedure with similar outcomes to patients without intervention.