Differential outcomes of ISHLT PGD 3 after ex-vivo lung perfusion compared to PGD 3 after direct transplantation

Primary graft dysfunction (PGD) remains the most feared complication in the early postoperative period after lung transplantation (LTx). Despite improved evaluation of marginal lungs with ex-vivo lung perfusion (EVLP), PGD 3 is still observed. We aimed to evaluate the outcomes of patients developing PGD 3 after EVLP.

This is a retrospective single-center study, including patients who received LTx between 2008 and 2021 in the Toronto Lung Transplant Program. The primary end-point was 90-day mortality. Propensity score weighting was applied to correct for possible confounders.

The final analysis included 1,871 patients, of which 538 lungs were transplanted after EVLP assessment using the Toronto EVLP technique. The incidence of grade 3 PGD was 38.1% and 20.8% (p < 0.001) on intensive care unit (ICU) admission and 13.2% and 12.1% (p = 0.445) at 72 hours for EVLP LTx and standard transplantation, respectively. The EVLP LTx group developing PGD 3 on arrival to ICU had a shorter median length of mechanical ventilation (82 vs 124 hours, p < 0.001), shorter length of stay in ICU (6 vs 12 days, p < 0.001), and shorter length of hospital stay (23 vs 41 days, p < 0.001) compared to standard LTx PGD 3 group. A lower 90-day mortality rate in the EVLP LTx group was observed compared to standard LTx (6% vs 11%, p = 0.078). Mortality rate at 1 year post-transplant for PGD 3 patients was similar between the groups.

The incidence of PGD 3 on admission to the ICU is higher after EVLP compared to standard transplantation. However, PGD 3 after acellular normothermic EVLP resolves within 24 hours and short-term outcomes are significantly improved compared to patients with PGD 3 after standard transplantation.