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Purpose: Delayed chest closure (DCC) during lung transplantation (LTx) is a controversial surgical approach that lacks research in systemic sclerosis (SSc) patients. We investigated outcomes, clinical risk factors, and CT‐based lung size‐matching parameters associated with DCC in SSc recipients. Methods: This retrospective study included 92 SSc recipients (age 51 years ± 10, 56/92 (61.0%) females) who underwent bilateral LTx between 2007 and 2020. Of the recipients, 34.8% (32/92) underwent DCC. Recipient lung and chest cavity volumes were automatically computed from CT imaging using deep learning algorithms. Survival between groups was compared using Kaplan–Meier analysis. Multivariate logistic regression was used to identify risk factors and predict DCC occurrence using preoperative variables. Results: Recipients who underwent DCC had longer total vent duration (p = 0.001), more use of postoperative mechanical support (p = 0.001), longer ICU length of stay (p = 0.008), and lower incidence of pneumonia post‐operation (p = 0.031). No significant difference in survival was observed between DCC and PCC recipients at 30 days (p = 0.713), 90 days (p = 0.267), 1 year (p = 0.941), and 5 years (p = 0.651). Clinical risk factors for DCC included BMI > 30 kg/m2 (p = 0.009), tracheostomy (p = 0.002), atrial fibrillation (p = 0.012), decreased preoperative FEV1/FVC (p = 0.013), and previous chest operation (p = 0.020). Two CT‐based measurements of lung matching were significantly associated with DCC occurrence (p = 0.021 and 0.050). The regression model achieved a mean AUC of 0.82 (0.70, 0.94) in retrospectively predicting DCC occurrence. Conclusion: SSc recipients undergoing DCC have similar survival rates but experience more complications than PCC recipients. Clinical risk factors and CT‐based size matching can be leveraged to predict DCC pre‐transplant. [ABSTRACT FROM AUTHOR]

Background: Early utilization of extracorporeal membrane oxygenation (ECMO) improves the clinical outcomes of patients with severe primary graft dysfunction (PGD3) after lung transplantation. Although there is a survival benefit, the impact of ECMO on airway complications has not been investigated. This study aims to describe the clinical association between posttransplant methods of support and the severity of acute airway anastomosis complications in patients with PGD3 following bilateral lung transplantation. Methods: Data from adult bilateral lung transplant patients diagnosed with PGD3 at our institution were retrospectively reviewed. Bronchial anastomosis necrosis (ischemia reperfusion injury [IRI]) that developed within a month after transplantation was graded. The data were compared among the groups of veno‐venous ECMO (VV‐ECMO) (n = 77), veno‐arterial ECMO (VA‐ECMO) (n = 14), and mechanical ventilation (MV, n = 33). Results: Higher levels of support (VV/VA‐ECMO) were associated with a lower incidence of PGD3, which was highest in recipients on MV only (M2 = 19.54, r = −0.41, p < 0.001). In a multivariable competing risk analysis, VV‐ECMO was protective against chronic allograft dysfunction (CLAD) relative to the MV group (HR: 0.36 [0.13–0.96], p = 0.042). There was no relationship between posttransplant support and survival. Conclusion: This study suggests posttransplant VV‐ECMO support in patients who develop PGD3 may confer a protective advantage over MV alone in the prevention of ischemic reperfusion injury. VV‐ECMO was associated with lower IRI grades and lower rates of BOS after transplantation. Future studies investigating the causal mechanisms are warranted. [ABSTRACT FROM AUTHOR]

Multiorgan transplantation is offered to a selected group of patients every year. The sequence in which organs are transplanted depends on ischemic time graft tolerance and the sickest organ first strategy. In the case of Lung‐Liver transplantation, lung allografts are usually implanted before the liver. There are some theoretical advantages to a liver‐first strategy and a few centers have reported a series of cases that spark a growing interest in the feasibility and potential benefits of this approach. In this contemporary study of the United Network for Organ Sharing (UNOS) database, we evaluate and report outcomes using either strategy. [ABSTRACT FROM AUTHOR]

Introduction: Lung transplantation has become increasingly utilized in patients with COVID‐19. While several single‐center and UNOS database studies have been published on lung transplants (LTs) for end‐stage lung disease (ESLD) from Coronavirus disease 2019 (COVID‐19), there is a lack of multi‐center and international data. Methods: This is a multicenter analysis from 11 high‐volume lung transplant centers in the United States and Europe. Data were collected through the Multi‐Institutional ECLS Registry and stratified by ESLD due to COVID‐19 versus other etiologies. Demographics and clinical variables were compared using Chi‐square test and Fisher's exact test. Survival was assessed by Kaplan‐Meier curves and compared by log‐rank test with propensity score matching. Results: Of 1606 lung transplant recipients, 46 (2.9%) were transplanted for ESLD from COVID‐19 compared to 1560 (97.1%) without a history of COVID‐19. Among COVID‐19 patients, 30 (65.2%) had COVID‐19‐associated ARDS and 16 (34.8%) had post‐COVID‐19 fibrosis. COVID‐19 patients had higher lung allocation scores (78.0 vs. 44.4, p < 0.0001), had severely limited functional status (37.0% vs. 2.9%, p < 0.0001), had higher preoperative ECMO usage (65.2% vs. 5.4%, p < 0.0001), and spent less time on the waitlist (32 vs. 137 days, p < 0.0001). A 30‐day survival was comparable between COVID‐19 and non‐COVID‐19 patients before (100% vs. 98.7%, p = 0.39) and after propensity matching (p = 0.15). Conclusions: Patients who received LTs due to COVID‐19 had short‐term survival comparable to that of patients without COVID‐19. Our findings support the idea that lung transplantation should be considered for select patients with ESLD due to COVID‐19. [ABSTRACT FROM AUTHOR]

Persistent acute kidney injury (pAKI), compared with acute kidney injury (AKI) that resolves in <72 h, is associated with worse prognosis in critically ill patients. Definitions and prognosis of pAKI are not well characterized in solid organ transplant patients. Our aims were to investigate (a) definitions and incidence of pAKI; (b) association with clinical outcomes; and (c) risk factors for pAKI among heart, lung, and liver transplant recipients. We systematically reviewed the literature including PubMed, Embase, Web of Science, and Cochrane from inception to 8/1/2023 for human prospective and retrospective studies reporting on the development of pAKI in heart, lung, or liver transplant recipients. We assessed heterogeneity using Cochran's Q and I2. We identified 25 studies including 6330 patients. AKI (8%–71.6%) and pAKI (2.7%–55.1%) varied widely. Definitions of pAKI included 48–72 h (six studies), 7 days (three studies), 14 days (four studies), or more (12 studies). Risk factors included age, body mass index (BMI), diabetes, preoperative chronic kidney disease (CKD), intraoperative vasopressor use, and intraoperative circulatory support. pAKI was associated with new onset of CKD (odds ratio [OR] 1.41–11.2), graft dysfunction (OR 1.81–8.51), and long‐term mortality (OR 3.01–13.96), although significant heterogeneity limited certainty of CKD and graft dysfunction outcome analyses. pAKI is common and is associated with worse mortality among liver and lung transplant recipients. Standardization of the nomenclature of AKI will be important in future studies (PROSPERO CRD42022371952). [ABSTRACT FROM AUTHOR]

Objective: Pediatric Heart‐lung transplant (HLTX) is performed for endstage congenital heart disease (CHD) with irreversible pulmonary hypertension or non‐congenital heart disease (NCHD) with end‐stage heart and lung disease. CHD could influence the outcomes of HTLX due to increased complexity of the operation as compared to NCHD. In this study we evaluated the influence of cardiac diagnosis on outcomes of pediatric HTLX. Methods: The UNOS database (1987–2022) was queried for primary HTLX in patients <18 years. The data were extracted for demographics, pretransplant characteristics, post‐transplant outcomes, and analyzed for the impact of cardiac diagnosis on post‐transplant outcomes. Standard statistical tests were used. Survival was compared using the Kaplan–Meier method. Results: Ninety of the 213 patients who underwent HLTX had CHD. There were no demographic differences. Heart listing status was similar but with a higher LAS score for NCHD. NCHD had higher pre‐operative life support use (mechanical ventilation, inotropes or dialysis) but the use of ECMO as a bridge to transplantation was similar. Wait‐list times were longer for CHD. The ischemic times were similar. Post‐transplant dialysis, stroke, prolonged mechanical ventilation, and rejection were similar. Survival at 30‐days, 1‐year, and long‐term survival at 17 years was similar. Non‐survivors at 30‐days post‐transplant were on life support, used ECMO as a bridge, had lower wait‐list times, longer ischemic times and had strokes. Non‐survivors at 1‐year had similar factors in addition to a higher dialysis use. Conclusion: Cardiac diagnosis had no impact on outcomes after Pediatric HLTX. Patients on life support or ECMO before transplantation were transplanted faster but with lower survival. [ABSTRACT FROM AUTHOR]

Objectives: End‐stage lung disease from primary pulmonary hypertension (PPHTN) and pulmonary venous‐occlusive disease (PVOD) may require lung transplantation (LT). While medical therapies exist for the palliation of PPHTN, no therapies exist for PVOD. The study's objective is to compare outcomes of LT in these patients. Methods: Patients with PPHTN and PVOD who had undergone LT were identified in the UNOS database (2005–2022). Univariable analyses compared differences between groups in demographic, clinical, and post‐transplant outcomes. Multivariable logistic regression examined the association between the diagnosis group and survival. Overall survival time between groups was compared using the Kaplan–Meier method. Results: Six hundred and ninety‐six PPHTN and 78 PVOD patients underwent LT during the study period. Patients with PVOD had lower pulmonary artery mean pressure (47 vs. 53 mmHg, p <.001), but higher cardiac output (4.51 vs. 4.31 L/min, p =.04). PVOD patients were more likely to receive lungs from donation after cardiac death donors (7.7 vs. 2.9%, p =.04). There were no differences in postoperative complications or length of stay. PVOD was associated with superior survival at 30‐day (100 vs. 93%, p =.02) and 90‐day post‐transplant (93 vs. 83%, p =.03), but not at later time points. In multivariable analyses, PVOD and brain death donor use were associated with better survival up to 90‐day mark. Conclusions: Patients undergoing LT for PVOD had better initial survival, which disappeared after 1 year of transplantation. Donation after circulatory death donor use had a short‐term survival disadvantage. [ABSTRACT FROM AUTHOR]

Background: The safety of lung transplantation using ex vivo lung perfusion (EVLP) has been confirmed in multiple clinical studies; however, limited evidence is currently available regarding the potential effects of EVLP on posttransplant graft complications and survival with mid‐ to long‐term follow‐up. In this study, we reviewed our institutional data to better understand the impact of EVLP. Methods: Lungs placed on EVLP from 2014 through 2020 and transplant outcomes were retrospectively analyzed. Data were compared between lungs transplanted and declined after EVLP, between patients with severe primary graft dysfunction (PGD3) and no PGD3 after EVLP, and between matched patients with lungs transplanted with and without EVLP. Results: In total, 98 EVLP cases were performed. Changes in metabolic indicators during EVLP were correlated with graft quality and transplantability, but not changes in physiological parameters. Among 58 transplanted lungs after EVLP, PGD3 at 72 h occurred in 36.9% and was associated with preservation time, mechanical support prior to transplant, and intraoperative transfusion volume. Compared with patients without EVLP, patients who received lungs screened with EVLP had a higher incidence of PGD3 and longer ICU and hospital stays. Lung grafts placed on EVLP exhibited a significantly higher chance of developing airway anastomotic ischemic injury by 30 days posttransplant. Acute and chronic graft rejection, pulmonary function, and posttransplant survival were not different between patients with lungs screened on EVLP versus lungs with no EVLP. Conclusion: EVLP use is associated with an increase of early posttransplant adverse events, but graft functional outcomes and patient survival are preserved. [ABSTRACT FROM AUTHOR]

Background: Despite advances in critical care for acute respiratory distress syndrome (ARDS), some survivors in the acute phase are unable to wean from extracorporeal membrane oxygenation (ECMO) or mechanical ventilation. To date, little is known regarding whether lung transplantation confers a survival benefit for irreversible ARDS. Methods: This retrospective study was conducted using the United Network for Organ Sharing database (May 2005–December 2018). Patients with restrictive lung disease were divided into two groups: patients with and without ARDS. Propensity score matching identified recipients without ARDS for the control group. Results: A total of 63 patients with ARDS were waitlisted for lung transplantation, while 39 received a lung transplant after a median waitlist duration of 8 days. Seventy‐eight patients were matched as controls. In the ARDS group, the median age was 30 years, and the median lung allocation score was 88.4. Among the 39 recipients, 30 (76.9%) received ECMO support prior to transplantation. Lung transplantation for ARDS and restrictive lung disease showed similar 90‐day (87.2% vs. 88.5%, p =.80), 1‐year (82.1% vs. 85.9%, p =.52), and 3‐year (69.2% vs. 65.4%, p =.94) survival rates. Conclusions: Lung transplantation provides acceptable outcomes in selected patients with irreversible ARDS. [ABSTRACT FROM AUTHOR]

Background: When the transplant candidates are receiving oral anticoagulation therapy before transplantation, it is crucial to have an urgent reversal strategy to prevent hemorrhagic complications perioperatively. The aim of this study was to present the experience with idarucizumab to reverse the anticoagulant activity of dabigatran prior to lung transplantation. Methods: A single‐center retrospective study was performed to analyze the clinical outcomes of idarucizumab use before lung transplantation. Results: Between July 2016 and June 2019, six patients were on dabigatran at the time of transplantation. Out of the six patients, four patients received idarucizumab. These four recipients received a median of 3 units (range 0‐4 units) of packed red blood cells (pRBCs) and 450 ml (range 250‐1500 ml) of intraoperative salvage of shed blood (cell saver blood) during the lung transplant. The two patients who were not administered idarucizumab received 5 units and 13 units of pRBCs and 900 ml and 3600 ml of cell saver blood, respectively. There was no grade 3 primary graft dysfunction (PGD) at 72 hours after transplantation or in‐hospital mortality in idarucizumab group. In the group without idarucizumab, there was one case of grade 3 PGD without any in‐hospital mortality. Conclusion: Dabigatran reversal with idarucizumab provides reasonable hemostasis during lung transplantation. [ABSTRACT FROM AUTHOR]