Risk Factors and Outcomes of Reintubation Following Combined Heart-Lung Transplantation

Unplanned reintubation after combined heart-lung transplantation (HLT) significantly affects morbidity and mortality, yet national data are limited. We evaluated the incidence, predictors, timing, and outcomes associated with reintubation after HLT.

We retrospectively reviewed adults undergoing primary HLT in the UNOS registry from January 2004 to September 2024. Patients were stratified by reintubation status (defined as re-established mechanical ventilation (MV) after initial extubation). Propensity matching (1:1) balanced recipient and donor characteristics. Multivariable logistic regression models identified independent risk factors.

Among 609 adult HLT recipients, 165 (27.1%) required postoperative reintubation. After 1:1 propensity score matching, 146 patients who were reintubated were compared with 146 patients who were successfully extubated. Reintubation was associated with significantly higher early mortality: 30-day (8.2% vs. 3.4%; p = 0.023), 90-day (11.6% vs. 5.5%; p = 0.030), and 6-month (15.1% vs. 8.2%; p = 0.028) mortality rates were all higher in the reintubated cohort, although long-term survival at 1, 3, and 5 years was similar between groups. Early graft failure was more frequent among reintubated patients at 30 days (5.5% vs. 0.7%; p = 0.018) and 90 days (6.2% vs. 1.4%; p = 0.031), with no significant differences thereafter. Reintubated recipients also demonstrated worse functional recovery at discharge (moderate-to-severe limitation: p = 0.012), longer duration of mechanical ventilation (extubated ≤48 h: 20.6% vs. 41.8%; p = 0.003), markedly prolonged hospital stays (73.4 ± 68.8 vs. 37.7 ± 35.3 days; p < 0.0001), and higher rates of stroke (5.5% vs. 3.4%; p = 0.035) and dialysis (37.7% vs. 20.6%; p = 0.001).

Reintubation after HLT significantly increases morbidity and mortality. Identified predictors provide actionable targets for enhanced perioperative airway management.