Limited cumulative experience with ex vivo lung perfusion is associated with inferior outcomes after lung transplantation

Objective: Ex vivo lung perfusion (EVLP) allows for prolonged preservation and evaluation/resuscitation of donor lungs. We evaluated the influence of center experience with EVLP on lung transplant outcomes.Methods: We identified 9708 isolated, first-time adult lung transplants from the United Network for Organ Sharing database (March 1, 2018-March 1, 2022), 553 (5.7%) involved using donor lungs after EVLP. Using the total volume of EVLP lung transplants per center during the study period, centers were dichotomized into low-(1-15 cases) and high-volume (>15 cases) EVLP centers.Results: Forty-one centers performed EVLP lung transplants, including 26 low-volume and 15 high-volume centers (median volume, 3 vs 23 cases; P <.001). Recipients at low-volume centers (n = 109) had similar baseline comorbidities compared with high-volume centers (n = 444). Low-volume centers used numerically more donation after circulatory death donors (37.6 vs 28.4%; P = .06) and more donors with PaO2/FiO(2) ratio<300 (24.8 vs 9.7%; P <.001). After EVLP lung transplants, low -volume centers had worse 1-year survival (77.8% vs 87.5%; P = .007), with an adjusted hazard ratio of 1.63 (95% CI, 1.06-2.50, adjusting for recipient age, sex, diagnosis, lung allocation score, donation after circulatory death donor, donor PaO2/FiO(2) ratio, and total annual lung transplant volume per center). When compared to non-EVLP lung transplants, 1-year survival of EVLP lung transplants was significantly worse at low-volume centers (adjusted hazard ratio, 2.09; 95% CI, 1.47-2.97) but similar at high-volume centers (adjusted hazard ratio, 1.14; 95% CI, 0.82-1.58).Conclusions: The use of EVLP in lung transplantation remains limited. Increasing cumulative EVLP experience is associated with improved outcomes of lung transplantation using EVLP-perfused allografts.