Improved survival after lung transplantation for adults requiring pre-operative invasive mechanical ventilation: A national cohort study

Abstract Objective Early survival after lung transplantation has improved in the last decade. Mechanically ventilated recipients are known to be at higher risk for early post-transplant mortality. We hypothesized that post-transplant survival in mechanically ventilated recipients has improved over time. Methods Using a national registry, we compared hazard of death at 30 days, 4 and 14 months, 3 and 5 years, and overall for adults on mechanical ventilation who underwent lung or heart-lung transplantation from May 4th, 2011 to April 4th, 2018 (modern group) to those undergoing transplantation from May 4th, 2005 to May 3rd, 2011 (early group). We quantified the impact of mechanical ventilation on survival using population attributable fractions. We also compared mechanically ventilated recipients to non-mechanically ventilated recipients. Results Mechanically ventilated recipients from the modern group had lower hazard of death than recipients in the early group at all time-points, lowest at 30-days post-transplant (hazard ratio 0.04 (95% confidence interval 0.02, 0.08). In the modern period, mechanically ventilated recipients had higher hazard of death than non-mechanically ventilated recipients at 30-days post-transplant (9.53 (4.57, 19.86). For mechanically ventilated recipients, the population attributable fraction was lower in the modern group compared to the earlier group (0.6% vs. 5.7%). Conclusions While mechanically ventilated recipients remain high-risk, survival in this patient population has improved over time. This may reflect improvements in perioperative recipient management.