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The impact of preoperative mechanical support on long-term survival following early lung re-transplantation for graft failure

Year: 2026

Type: article

Abstract: Objective Severe graft failure after lung transplantation is a devastating outcome with limited therapeutic options. Mechanical support provides temporary stabilization but may compromise re-transplantation candidacy. This study examined postoperative outcomes and long-term survival of graft failure re-transplants by preoperative mechanical support use. Methods The UNOS database was queried for adults undergoing early re-transplantation for graft failure (EGF) performed within one year of the primary transplant from 2005-2025. Primary transplants, multiorgan, and re-transplants from unknown causes were excluded. Patients were stratified by preoperative mechanical support use (ventilation and/or ECMO). The primary outcome was five-year survival. Results Among 1,453 re-transplants, 140 (9.6%) were for EGF. 85 (61%) required preoperative mechanical support (61%), and 55 did not (39%). Within the mechanical support group, 72 (85%) were ventilated, 44 (52%) received ECMO, and 31 (36%) had both ECMO and ventilation. Supported patients had higher LAS scores (89.3 vs 71.6, p<0.001) and more dialysis use (24% vs 1%, p<0.001). Postoperatively, supported patients experienced more prolonged ventilation (34% vs 16%, p=0.02) and more ECMO support (20% vs 9%, p=0.03). Ninety-day mortality was equivalent (27.1% vs 16.4%, p=0.14). However, mechanical support use of any form was associated with higher five-year mortality (adjusted HR 1.71 [1.02 – 2.85], p=0.04). Combined ventilator and ECMO use had the worst long-term survival compared to no mechanical support (aHR 2.13 [1.03 – 4.40], p=0.04). Conclusion Preoperative mechanical support was associated with greater postoperative morbidity and worse long-term survival. These findings underscore the need to critically evaluate whether re-transplantation truly benefits this high-risk population.

Source: JHLT Open

DOI: 10.1016/j.jhlto.2026.100626