Re-operative lung transplantation (LTx) survival has improved over time such that a growing number of patients may present for third-time LTx (L3Tx). To understand the safety of L3Tx, we evaluated perioperative outcomes and three-year survival after L3Tx at a high-volume US LTx center.
This retrospective study included all patients who underwent bilateral L3Tx at our institution. Using an optimal matching technique, a primary LTx (L1Tx) cohort was matched 1:2 and a second-time LTx (L2Tx) cohort 1:1. Recipient, operative, and donor characteristics, perioperative outcomes, and three-year survival were compared among L1Tx, L2Tx, and L3Tx groups.
11 L3Tx, 11 L2Tx, and 22 L1Tx recipients were included. Among L3Tx recipients, median age at transplant was 37 years and most (73%) had cystic fibrosis. L3Tx was performed median 6.0 and 10.6 years after L2Tx and L1Tx, respectively. Compared to L1Tx and L2Tx recipients, L3Tx recipients had greater intraoperative transfusion requirements, a higher incidence of post-operative complications, and a higher rate of unplanned reoperation. Rates of grade 3 primary graft dysfunction at 72 hours (PGD3), ECMO at 72 hours, reintubation, and in-hospital mortality were similar among groups. There were no differences in three-year patient (log-rank p=0.61) or rejection-free survival (log-rank p=0.34) after L1Tx, L2Tx, and L3Tx.
At our institution, L3Tx was associated with similar perioperative outcomes and three-year patient survival compared to L1Tx and L2Tx. L3Tx represents the only safe treatment option for patients with allograft failure after L2Tx; however, further investigation is needed to understand the long-term survival and durability of L3Tx.

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