Lung Transplantation After Ex Vivo Lung Perfusion in High-Risk Recipients: A Propensity Matched Analysis of a National Database.

Purpose: We report outcomes associated with EVLP lungs in high-risk lung transplant recipients utilizing a national database.

Methods: We performed a retrospective analysis of the UNOS Database (1/1/2018-3/31/2024). High-risk status was defined as mean pulmonary arterial pressure > 35 mmHg, lung retransplantation, or bridge to transplant. In addition to univariable analysis, propensity score matched analysis was performed on predictors of donor and recipient characteristics.

Results: Risk of dying on the waitlist was significantly higher for high-risk candidates (HR: 1.69 [1.51 - 1.89], p < 0.001). Following matching, 203 EVLP cases were matched to 609 standard procurement recipients. The EVLP group was associated with higher rates of postoperative acute kidney injury requiring renal replacement therapy (27% vs 16%, p < 0.001), higher mortality on index admission (13% vs. 8%, p = 0.04), and longer length of stay (29 vs 25 days, p = 0.006). EVLP modality was associated with survival time (p < 0.001) with portable EVLP having significantly shorter survival (2.7 years) relative to standard cases (4.7 years, p < 0.02). A subgroup analysis found that this survival effect was limited to bridge and retransplant recipients.

Conclusions: EVLP lungs were associated with higher rates of postoperative AKI and portable EVLP was associated with shorter survival in high-risk lung transplant recipients. However, given the high waitlist mortality in this candidate population, EVLP lungs should still be considered an alternative.