Graft survival in single versus bilateral lung transplantation for emphysema

The benefits of bilateral lung transplantation (BLT) vs single lung transplantation (SLT) are still debated. One impediment to clinical recommendations is that BLT vs SLT advantages may vary based on underlying disease. Because both options are clinically tenable in patients with emphysema, we conducted a comprehensive assessment of lung allograft survival in this population. Using US registry data, we studied time to all-cause allograft failure in 8092 patients 12 years or older, transplanted from 2006 to 2022, adjusting for recipient, donor, and transplant factors by inverse propensity weighting. Median allograft survival was 6.6 years in BLT compared to 5.3 years in SLT, a 25% risk-adjusted survival advantage of _0.81.3_1.8 years. Risk-adjusted bilateral survival advantages varied between 0.9 and 2.4 years across 11 subgroups. Median allograft survival in BLT was 1.2 years greater than right SLT and 2.0 years greater than left SLT. During the 16-year study period, allograft survival steadily improved for BLT but not for SLT. Although the 25% BLT survival advantage predated the coronavirus 2019 (COVID-19) pandemic, COVID-19 may have contributed to an apparent SLT survival decline. Recognizing the possible influence of residual confounding due to selection biases, these findings may aid offer decision-making when both donor lungs are available.