Background: Primary graft dysfunction (PGD) has detrimental effects on recipients following lung transplantation. Here, we determined the contemporary trends of PGD in a national database, factors associated with the development of PGD grade 3 (PGD3) and ex vivo lung perfusion’s (EVLP) effect on this harmful postoperative complication. Methods: The United Network for Organ Sharing database was queried from 2015 to 2023, and recipients were stratified into No-PGD, PGD1/2, or PGD3. The groups were analyzed with comparative statistics, and survival was determined with Kaplan–Meier methods. Multivariable Cox regression was used to determine factors associated with increased mortality. PGD3 recipients were then stratified based on EVLP use prior to transplantation, and a 3:1 propensity match was performed to determine outcomes following transplantation. Finally, logistic regression models based on select criteria were used to determine risk factors associated with the development of PGD3 and mortality within 1 year. Results: A total of 21.4% of patients were identified as having PGD3 following lung transplant. Those with PGD3 suffered significantly worse perioperative morbidity, mortality, and had worse long-term survival. PGD3 was also independently associated with increased mortality. Matched EVLP PGD3 recipients had significantly higher use of ECMO postoperatively; however, they did not suffer other significant morbidity or mortality as compared to PGD3 recipients without EVLP use. Importantly, EVLP use prior to transplantation was significantly associated with decreased likelihood of PGD3 development, while having no significant association with early mortality. Conclusions: EVLP is associated with decreased PGD3 development, and further optimization of this technology is necessary to expand the donor pool.

Heparin-induced thrombocytopenia (HIT) in patients on mechanical circulatory support (MCS) prior to lung transplantation poses a unique challenge of balancing thrombotic versus hemorrhagic complications. An alternative method of anticoagulation is bivalirudin, offering advantages of rapid titration and a short half-life. We present 2 cases of patients on MCS who developed HIT and were anticoagulated with bivalirudin preoperatively. Contingent on whether additional cannulation was required at the time of lung transplantation, bivalirudin was held either at incision or after cannulation. Both patients were successfully transplanted without coagulopathic complications.

Accurate donor–recipient allograft size matching remains a critical determinant of outcomes in lung transplantation, yet current approaches rely predominantly on predicted total lung capacity (pTLC) and height-based metrics derived from population-based equations. These simplified surrogates fail to capture individual anatomical variability, disease-specific alterations in thoracic geometry, and the spatial relationship between donor lungs and recipient chest cavities. In this review, we examine the limitations of conventional size matching and synthesize emerging evidence supporting imaging-based approaches, including computed tomography (CT) volumetry, radiomics, and machine learning. CT-derived volumetric analysis enables individualized anatomical assessment and has been associated with clinically relevant prediction of primary graft dysfunction and mortality. Advanced computational methods may further support the extraction of imaging-derived features and integration with clinical data, although these approaches remain investigational. Collectively, these developments signal a paradigm shift from crude population-based metrics toward imaging-driven and computational approaches in the modern era. With rigorous validation and careful clinical integration, imaging-based approaches may complement conventional size metrics and support more individualized donor–recipient assessment.

BACKGROUND The utilization of hearts from older donors has increased, particularly for older recipients. However, the impact of older donor hearts on recipients of different ages is less known. AIM To determine the impact of older donor hearts on post-transplant outcomes across different recipient age groups. METHODS The Organ Procurement and Transplant Network database was queried from 2006 to March 2024. Four groups were created stratifying by donor age (> 55 years) and recipient age (> 60 years). Kaplan-Meier curves and Cox regression models were used. RESULTS One thousand fifty out of 39868 transplants (2.6%) were performed utilizing hearts from older donors. The rate of older donor hearts in younger recipients was only 1.8%, while the older donor hearts were used 4.0% in older recipients (P < 0.001). Old donor/old recipient and young donor/old recipient combinations were associated with post-transplant mortality [hazard ratio (HR): 1.64 (95%CI: 1.42-1.90) and 1.42 (95%CI: 1.34-1.51)], while old donor/young recipient was not. Within each recipient age group, the older recipient groups showed greater differences in 1- and 5-year survival probabilities (80.4% and 67.4% with old donors, 89.2% and 76.8% with young donors) than younger recipient groups (90.3% and 77.5% with old donors, 92.2% and 80.3% with young donors). CONCLUSION This study demonstrates the higher utilization of older donor hearts (aged more than 55) in older recipients. Paradoxically, the combination of older donor hearts with older recipients is associated with a higher risk of mortality. However, these organs remain valuable options across all recipient age groups in current context of organ shortage.

Accurate donor-recipient allograft size matching remains a critical determinant of outcomes in lung transplantation, yet current approaches rely predominantly on predicted total lung capacity (pTLC) and height-based metrics derived from population-based equations. These simplified surrogates fail to capture individual anatomical variability, disease-specific alterations in thoracic geometry, and the spatial relationship between donor lungs and recipient chest cavities. In this review, we examine the limitations of conventional size matching and synthesize emerging evidence supporting imaging-based approaches, including computed tomography (CT) volumetry, radiomics, and machine learning. CT-derived volumetric analysis enables individualized anatomical assessment and has been associated with clinically relevant prediction of primary graft dysfunction and mortality. Advanced computational methods may further support extraction of imaging-derived features and integration with clinical data, although these approaches remain investigational. Collectively, these developments signal a paradigm shift from crude population-based metrics toward imaging-driven and computational approaches in the modern era. With rigorous validation and careful clinical integration, imaging-based approaches may complement conventional size metrics and support more individualized donor-recipient assessment.