Lung Transplant Outcomes After Acute Respiratory Distress Syndrome Requiring Extracorporeal Life Support—Lessons from the Coronavirus Disease Pandemic

OBJECTIVE:Lung transplant for acute respiratory distress syndrome (ARDS) in patients supported with extracorporeal membrane oxygenation (ECMO) was rare prior to 2020, but was rapidly adopted to save COVID-19 patients with lung failure. This study aims to compare the outcomes of patients who underwent lung transplant for COVID-associated ARDS (CARDS) and non-COVID ARDS (NCARDS), and to assess the impact of type and duration of ECMO support on survival. METHODS:Using the UNOS database, we identified 311 patients with ARDS who underwent lung transplant from 2007 to 2022 and performed a retrospective analysis of the patients who required ECMO preoperatively, stratified by CARDS and NCARDS listing diagnoses. The primary outcome was 1-year survival. Secondary outcomes included the effect of type and duration of ECMO on survival. RESULTS:During the study period, 236 patients with ARDS and preoperative ECMO underwent lung transplant; 181 had a listing diagnosis of CARDS (77%) and 55 of NCARDS (23%). Patients with CARDS were older, more likely to be female, had higher BMI, and spent longer on the waitlist (all p<0.02) than patients with NCARDS. The two groups had similar 1-year survival (85.8% vs 81.1%, p=0.2) with no differences in postoperative complications. Patients with CARDS required longer times on ECMO pretransplant (p=0.02), but duration of ECMO support was not a predictor of 1-year survival (p=0.2). CONCLUSIONS:Despite prolonged periods of pretransplant ECMO support, selected patients with ARDS can undergo lung transplant safely with acceptable short-term outcomes. Appropriate selection criteria and long-term implications require further analysis.