Acute respiratory distress syndrome (ARDS) is a rapidly progressive lung disease with a high mortality rate. Although lung transplantation (LTx) is a well-established treatment for a variety of chronic pulmonary diseases, LTx for acute lung failure (due to ARDS) remains controversial. We reviewed posttransplant outcome of ARDS patients from three high-volume European transplant centers. Demographics and clinical data were collected and analyzed. Viral infection was the main reason for ARDS (n = 7/13, 53.8%). All patients were admitted to ICU and required mechanical ventilation, 11/13 were supported with ECMO at the time of listing. They were granted a median LAS of 76 (IQR 50-85) and waited for a median of 3 days (IQR 1.5-14). Postoperatively, median length of mechanical ventilation was 33 days (IQR 17-52.5), median length of ICU and hospital stay were 39 days (IQR 19.5-58.5) and 54 days (IQR 43.5-127). Prolongation of peripheral postoperative ECMO was required in 7/13 (53.8%) patients with a median duration of 2 days (IQR 2-7). 30-day mortality was 7.7%, 1 and 5-year survival rates were calculated as 71.6% and 54.2%, respectively. Given the lack of alternative treatment options, the herein presented results support the concept of offering live-saving LTx to carefully selected ARDS patients.

Objective: To determine the impact of prolonged storage of donor lungs at 10 °C for up to 24 hours on outcome after lung transplantation. Background: An increasing body of evidence suggests 10 °C as the optimal storage temperature for donor lungs. A recent study showed that cold ischemic times can be safely expanded to >12 hours when lungs are stored at 10 °C. However, it is currently unknown how long donor lungs can be preserved before they deteriorate in function. Methods: Patients who received a donor lung stored at 10 °C between November 2020 and June 2023 at the lung transplant programs of Toronto, Vienna, and Madrid were included in this retrospective analysis. After excluding ex-vivo lung perfusion cases, recipients were grouped based on the total preservation times of their donor organs (<12 hours: n = 48; 12–18 hours: n = 109; ≥18 hours: n = 24). Three hundred seventy-two recipients who had received an organ stored on-ice during the study period served as a control group. Results: Length of lung preservation ranged from 2 hours 27 minutes to 29 hours 33 minutes (mean: 14 hours 06 minutes). Despite these prolonged preservation times, early postoperative outcomes were excellent. Median length of mechanical ventilation did not differ among the 3 study groups [<12 hours: 41 hours (interquartile range: 24–109); 12–18 hours: 56 hours (interquartile range: 24–143) and ≥18 hours: 59 hours (interquartile range: 28–108); P = 0.493]. Intensive care unit length of stay [6 days (4–14); 8 days (4–23); 8 days (5–32)] and hospital length of stay [32 days (20–48); 29 days (20–50); 26 days (17–50)] were also similar. Furthermore, the length of donor organ preservation had no impact on patient survival (log-rank P = 0.413). Conclusions: Prolonged static preservation of donor lungs at 10 °C for up to 24 hours is safe and does not impair short-intermediate outcomes after lung transplantation.

Objectifying donor lung quality is difficult and currently there is no consensus. Several donor scoring systems have been proposed in recent years. They all lack large‐scale external validation and widespread acceptance. A retrospective evaluation of 2201 donor lungs offered to the lung transplant program at the Medical University of Vienna between January 2010 and June 2018 was performed. Five different lung donor scores were calculated for each offer (Oto, ET, MALT, UMN‐DLQI and ODSS). Prediction of organ utilization, 1y‐graft‐survival and long‐term outcome was analyzed for each score. 1049 organs were rejected at the initial offer (group I), 209 lungs declined after procurement (group II) and 841 lungs accepted and transplanted (group III). The Oto score was superior in predicting acceptance of the initial offer (AUC:0.795;CI:0.776‐0.815) and actual donor utilization (AUC:0.660;CI:0.618‐0.701). Prediction of 1y‐graft‐survival was best using the MALT‐score, Oto score and UMN‐DLQI. Stratification of early outcome by MALT was significant for length of mechanical ventilation, PGD3 rates, ICU‐stay and hospital‐stay, and in‐hospital‐mortality, respectively. To the best of our knowledge, this study is the largest validation analysis comparing currently available donor scores. The Oto score was superior in predicting organ utilization, MALT‐score and UMN‐DLQI for predicting outcome after lung transplantation.

Severe chest wall deformities are considered an absolute contraindication for lung transplantation. The significantly impaired chest compliance associated with pectus excavatum is thought to result in a high risk of postoperative respiratory complications and significant morbidity and mortality. We herein report our pooled institutional experience consisting of three patients who underwent bilateral lung transplantation and simultaneous correction of a pectus excavatum. Two of the patients were children and one patient suffered from a severe asymmetric pectus. All patients received a size‐reduced double lung transplant and the deformity was corrected by a Nuss or modified Ravitch procedure. Perioperative course was complicated by prolonged weaning requiring tracheostomy in two of the three patients. However, long‐term results were good and all three patients are alive in an excellent clinical condition 72, 60 and 12 months after the transplantation. This case series demonstrates that patients with severe chest wall deformities should not a priori be excluded from lung transplantation and a combined approach is feasible for selected patients.

Lung transplantation (LTx) can be considered for selected patients suffering from COVID-19 acute respiratory distress syndrome (ARDS). Secondary sclerosing cholangitis in critically ill (SSC-CIP) patients has been described as a late complication in COVID-19 ARDS survivors, however, rates of SSC-CIP after LTx and factors predicting this detrimental sequela are unknown. This retrospective analysis included all LTx performed for post-COVID ARDS at 8 European LTx centers between May 2020 and January 2022. Clinical risk factors for SSC-CIP were analyzed over time. Prediction of SSC-CIP was assessed by ROC-analysis. A total of 40 patients were included in the analysis. Fifteen patients (37.5%) developed SSC-CIP. GGT at the time of listing was significantly higher in patients who developed SSC-CIP (median 661 (IQR 324-871) vs 186 (109-346); p = 0.001). Moreover, higher peak values for GGT (585 vs 128.4; p < 0.001) and ALP (325 vs 160.2; p = 0.015) were found in the ‘SSC’ group during the waiting period. Both, GGT at the time of listing and peak GGT during the waiting time, could predict SSC-CIP with an AUC of 0.797 (95% CI: 0.647-0.947) and 0.851 (95% CI: 0.707-0.995). Survival of ‘SSC’ patients was severely impaired compared to ‘no SSC’ patients (1-year: 46.7% vs 90.2%, log-rank p = 0.004). SSC-CIP is a severe late complication after LTx for COVID-19 ARDS leading to significant morbidity and mortality. GGT appears to be a sensitive parameter able to predict SSC-CIP even at the time of listing.

The investigation of biomarkers associated with undesired outcome following lung transplantation (LuTX) is essential for a better understanding of the underlying pathophysiology, an earlier identification of susceptible recipients and the development of targeted therapeutic options. We therefore determined the longitudinal perioperative course of putative cytokines related to neutrophil activation (chemokine CC motif ligand 4 (CCL-4), interleukin (IL)-23 and Lipocalin 2 (LCN2)) and a cytokine that has been implicated in graft-versus-host disease (Follistatin-like 1 (FSTL1)) in 42 consecutive patients undergoing LuTX. We plotted receiver-operating curves (ROC) to assess the predictive power of the measured cytokines for short-term outcomes namely primary graft dysfunction (PGD), early complications requiring extracorporeal membrane oxygenation (ECMO), and a high postoperative sequential organ failure assessment (SOFA). All cytokines increased immediately after surgery. ROC analyses determined significant associations between CCL4 and a high SOFA score (area under the curve (AUC) 0.74 (95%CI:0.5–0.9; p < 0.05), between LCN2 and postoperative ECMO support (AUC 0.73 (95%CI:0.5–0.9; p < 0.05), and between FSTL1 and PGD (AUC 0.70 (95%CI:0.5–0.9; p < 0.05). The serum concentrations of the neutrophil-derived cytokines LCN2 and CCL4 as well as FSTL1 were all related to poor outcome after LuTX. The specific predictive power, however, still has to be assessed in larger trials. The potential role of FSTL1 as a biomarker in the development of PGD could be of great interest particularly since this protein appears to play a crucial role in allograft tolerance.