Dear Editors, Lung transplantation (LuTX) is an established and effective therapeutic option for patients with end-stage lung disease [1]. Over the past decades, advances in surgical techniques, perioperative management, immunosuppressive strategies, and long-term follow-up care have resulted in significant improvements in survival rates, health-related quality of life, and functional capacity after lung transplantation [2]. Consequently, many recipients are able to resume a broad range of physical activities, including high-intensity and endurance sports. Early publications on this topic are available from other solid organ transplant recipients [3]. In this context, participation in high-altitude mountaineering has been documented in carefully selected liver transplant recipients under close medical supervision [4]. In 2015 a transplanted patient reached the highest mountain peak (6.189m, Island Peak, Nepal) ever [5]. Also, lung transplant recipients are able to adapt to altitude and capable of performing prolonged exercise at high altitude after slow ascent [6,7]. In 2017 eight lung transplanted patients successfully summited Mount Kilimanjaro (5.895 m, Tanzania) under guidance of the Vienna lung transplant team [7,8]. Available evidence suggests that transplanted lungs retain the capacity to physiologically adapt to hypobaric hypoxia and can sustain prolonged physical exertion at high altitude, provided that ascent is gradual and appropriate acclimatization is ensured [7]. Eleven lung transplant recipients reached the summit of Mount Jebel Toubkal (4.167 m, Morocco) in 2019 without any adverse events, despite poorer cardiopulmonary performance compared to healthy volunteers [9]. In addition, they show stable immunosuppressive drug trough levels and Torque Teno virus loads indicate good tolerance relative to physical stress (Mühlbacher, 2026, under review).As part of an international medical expedition under guidance of the Vienna lung transplant team and the respective national team leaders, nine transplanted patients (8 patients after lung transplantation, one patient after liver transplantation) were included to climb Mount Aconcagua (6.961m, Argentina) in January 2026. The expedition was supported by an accompanying team of physicians and professional guides. The actual tour planning was carried out by a professional expedition provider (Furtenbach Adventures GmbH, Rum, Austria) in cooperation with a local expedition provider (Grajales Expeditions, Los Penitentes, Mendoza Province), both of whom have many years of experience in planning and safely conducting expeditions. The selection of possible candidates was based on lung function and spiroergometry and was done in accordance with the included transplant centers in Austria, Switzerland, Croatia, Denmark and the USA.Hypoxic conditioning (HC) applied at home as a pre-acclimatization strategy prior to high-altitude exposure may facilitate high-altitude ascents with a reduced risk of developing acute mountain sickness (AMS) [10,11]. However, standardized protocols remain insufficiently defined, and robust scientific data are limited, although pre-acclimatization appears to be a key determinant in the success of rapid ascent expeditions [12]. It is currently unknown how this form of pre-acclimatization affects patients after lung transplantation. To maximize participant safety during the expedition, however, all participants completed a structured home-based HC program comprising at least 200 hours of exposure prior to departure [10]. Participants completed mandatory safety and first aid training prior to the expedition; high flow oxygen systems (Summit Elite System, Summit Oxygen International Ltd) and carbon oxygen cylinders (4L, working pressure 300 bar; Armotech, Czech Republic) where available throughout the expedition for safety reasons.The expedition to Mount Aconcagua (6.962 m, Argentina), followed a structured 19day schedule organized by experienced professional providers. Accordingly, the ascent followed a standard acclimatization protocol via the normal route: approach to Plaza de Mulas Base Camp (BC) (4.350 m) over four days, followed by progressive establishment of higher camps at Plaza Canadá (5.050 m), Nido de Cóndores (5.560 m), and Camp Cólera (6.080 m). The summit attempt (6.961 m) was performed from High Camp Cólera (Figure 1A). Additional days were reserved for weather contingency and descent. Physiological monitoring, including heart rate and peripheral oxygen saturation, was performed using wearable devices provided within the framework of the project. In addition, the Lake Louise Acute Mountain Sickness (AMS) score was assessed daily based on self-reported symptoms documented by the mountaineers [13].On January 24, a lung transplant recipient successfully reached the summit of Mount Aconcagua (6,962 m, Argentina) together with the accompanying expedition team, without the use of supplemental oxygen. The ascent and descent were completed without adverse clinical events. In particular, no signs or symptoms consistent with high-altitude pulmonary edema (HAPE) or high-altitude cerebral edema (HACE) were observed during high-altitude exposure.This 51-year-old male lung transplant recipient (BMI 18.3 kg/m²), transplanted in 2002 for cystic fibrosis, resided at 407 m above sea level. Relevant comorbidities included diabetes mellitus and chronic kidney disease (creatinine: 2.57 mg/dl, November 2025); maintenance immunosuppression consisted of once-daily 0.75mg extended-release tacrolimus in combination with everolimus 0.5mg twice daily. He had prior high-altitude exposure, including Mount Kilimanjaro (5,895 m, Tanzania) [7], without any history of AMS, HAPE, or HACE. Baseline functional assessment demonstrated a maximal oxygen uptake (VO₂max) of 30.9 ml•kg⁻¹•min⁻¹ (90% predicted; maximal workload 140 W) and an FEV₁ of 2.7 L (86% predicted), indicating preserved exercise capacity and stable graft function prior to the expedition. As part of the pre-acclimatization strategy, the lung transplant recipient completed 311 hours of HC over 36 days (Figure 1B). Following HC, hemoglobin levels remained stable (from 13.7 to 13.8 g/dl). As simulated altitude increased during the preacclimatization phase, the participant experienced only mild symptoms, which was accompanied by a corresponding elevation in AMS scores (maximum AMS-Score of 2, Figure 1B). On the mountain he reported only mild to moderate symptoms of AMS (maximum AMS-Score of 5), and no instances of HAPE or HACE occurred at any point during the expedition (Figure 1C Resting SpO2 values progressively declined with increasing altitude from of 89% at BC to 75% at Camp 3. In contrast, heart rate remained relatively stable throughout the stay on the mountain, with average values ranging from 90 bpm at BC to 95 bpm at Camp 3. In summary, selected patients after lung transplantation are able to tolerate and physiologically adapt to high-altitude exposure when preceded by normobaric hypoxic preacclimatization, without experiencing severe high-altitude-associated complications.Moreover, one lung transplant recipient successfully summited Mount Aconcagua without supplemental oxygen, which, to our knowledge, constitutes the highest reported altitude reached following lung transplantation.Ethical approval was granted by the Ethics Committee of the Medical University of Vienna (2105/2025). The study was performed in accordance with national regulations and institutional guidelines. All participants provided written informed consent before participation.

Following lung transplantation (LuTx), some patients attain good long-term health, enabling participation in demanding activities, including high-altitude mountaineering. High-altitude exposure induces substantial physical stress through hypoxia, exhaustion and ultraviolet (UV) radiation, potentially compromising immunocompetence. Levels of immunosuppression and Torque Teno virus (TTV), a persistent, non-pathogenic DNA virus associated with immunocompetence after LuTX, were measured during an expedition to Mount Jebel Toubkal (4167 m), evaluating the effects of high-altitude exposure, physical exertion and UV radiation. Immunosuppression levels were evaluated in 14 LuTx recipients and compared to those of 12 healthy controls through TTV quantification before, during and after the expedition. A microsampling device (MSD) was validated in the cohort by comparing capillary blood samples with EDTA plasma samples to enable measurements in remote areas. Immunosuppression levels were determined using liquid chromatography-tandem mass spectrometry, and TTV DNA was quantified using real-time polymerase chain reaction. TTV DNA was detectable in 13 LuTx recipients (92.8%) and 10 healthy controls (83.3%). The LuTx recipients had significantly higher baseline TTV loads than the healthy controls (p =  < 0.0001), and the female recipients exhibited significantly higher TTV loads than their male counterparts (p = 0.047). The TTV levels remained stable throughout the expedition and weeks afterward in both LuTx recipients (p = 0.998) and healthy controls (p = 0.852). The average TTV load was 1.27 log10 copies/mL lower in the MSD than in the EDTA plasma. The tacrolimus and everolimus trough levels remained stable during the expedition (p = 0.326 and 0.894, respectively). Eleven LuTx recipients reached the summit without any adverse events, proving extreme physical exertion, even at high altitudes, safe for selected patients. The stable immunosuppressive drug trough levels and TTV loads indicate good tolerance relative to physical stress. MSDs represent a valuable tool for monitoring TTV and immunosuppressive drug trough levels in remote or resource-limited settings.

Background: An erector spinae plane block (ESPB) has gained popularity due to its effectiveness and simplicity for pain relief. However, it is uncertain whether an ESPB provides superior analgesia after a VATS or thoracotomy compared to other regional and systemic analgesic techniques. Methods: A retrospective cohort study was conducted from January to June 2023 comparing an ESPB with intravenous combination analgesia (IV–CA) in VATS patients and with thoracic epidural analgesia (TEA) in thoracotomy patients. The primary endpoint was the opioid demand during the first two hours in the post-anesthesia care unit (PACU). The secondary outcomes included the pain scores and adverse events. Results: A total of 61.2% of the 165 included VATS patients and 56.9% of the 72 thoracotomy patients were treated with an ESPB. Following a VATS, an ESPB decreased the median piritramide demand (7.5 [3.0 to 12.0] vs. 10.5 [6.5 to 15.5] mg, p < 0.01). However, after a thoracotomy, an ESPB increased the median piritramide demand (12.0 [6.0 to 15.0] vs. 3.0 [0.0 to 9.0] mg, p < 0.01). The pain scores and adverse events were similar between the groups. Conclusions: An ESPB reduces the piritramide demand in VATS patients compared with IV–CA, providing similar pain relief. However, in thoracotomy patients, an ESPB is associated with an increased piritramide demand compared to TEA. An ESPB is an attractive add-on to IV–CA after a VATS, while TEA remains the gold standard after a thoracotomy.

OBJECTIVES: Lung volume reduction surgery (LVRS) is an established treatment approach for patients with severe pulmonary emphysema, enhancing lung function and quality of life in selected patients. Functional benefits and outcomes after uni- versus bilateral lung volume reduction remain a topic of debate. METHODS: A retrospective analysis of patients undergoing LVRS from January 2018 to October 2022 was conducted. After encouraging initial results, the standard unilateral LVRS approach was switched to bilateral. The goal of this study was to assess the impact on functional outcomes at 3 and 6 months post-surgery compared to preoperative levels for the uni- versus the bilateral approach. RESULTS: A total of 83 patients were included (43 bilateral, 40 unilateral). Baseline demographic and functional parameters were comparable between groups. The most common complication was prolonged air leak in 19 patients (11 in the unilateral group, 8 in the bilateral group). Two patients died perioperatively (2.4%). Overall, LVRS improved forced expiratory volume in 1 s by 8.3% after 3 and 12.5% after 6 months postoperatively compared to baseline. Bilateral surgery presented significantly superior forced expiratory volume in 1 s improvement than unilateral approach at both 3 (29.2% versus 2.9%; P = 0.0010) and 6 months (21.5% versus 3%; P = 0.0310) postoperatively. Additionally, it reduced hyperinflation (residual volume) by 23.1% after 3 months and by 17.5% after 6 months, compared to reductions of 16% and 9.1% in the unilateral group. CONCLUSIONS: Bilateral approach resulted in better functional outcomes 3 and 6 months postoperatively compared to unilateral surgery.

OBJECTIVES:Compared to lung resections, airway procedures are relatively rare in thoracic surgery. Despite this, a growing number of dedicated airway centres have formed throughout Europe. These centres are characterized by a close interdisciplinary collaboration and they often act as supra-regional referring centres. To date, most evidence of airway surgery comes from retrospective, single-centre analysis as there is a lack of large-scale, multi-institutional databases. METHODS:In 2018, an initiative was formed, which aimed to create an airway database within the framework of the ESTS database (ESTS-AIR). Five dedicated airway centres were asked to test the database in a pilot phase. A 1st descriptive analysis of ESTS-AIR was performed. RESULTS:A total of 415 cases were included in the analysis. For adults, the most common indication for airway surgery was post-tracheostomy stenosis and idiopathic subglottic stenosis; in children, most resections/reconstructions had to be performed for post-intubation stenosis. Malignant indications required significantly longer resections [36.0 (21.4-50.6) mm] when compared to benign indications [26.6 (9.4-43.8) mm]. Length of hospital stay was 11.0 (4.1-17.3) days (adults) and 13.4 (7.6-19.6) days (children). Overall, the rates of complications were low with wound infections being reported as the most common morbidity. CONCLUSIONS:This evaluation of the 1st cases in the ESTS-AIR database allowed a large-scale analysis of the practice of airway surgery in dedicated European airway centres. It provides proof for the functionality of ESTS-AIR and sets the basis for rolling out the AIR subsection to all centres participating in the ESTS database.

Abstract Background Whole lung transpulmonary chemoembolization using a combination of doxorubicin (DXO) and degradable starch microspheres (DSM-TPCE) might be a promising treatment option in soft tissue sarcoma. To pave the way for clinical studies, this study aimed to evaluate the short-term effects of DSM-TPCE with DXO using an ex vivo isolated lung perfusion (ILP) model. Methods Nine lung specimens retrieved from patients undergoing lobectomy underwent ex vivo ILP. In groups of three, lung specimens were either treated with sole DXO, sole DSM, or combined substances (DSM + DXO). During ex vivo ILP, histological samples were obtained from each lung every 15 min. Quantitative DXO analysis and histopathological grading of possible tissue damage using a five-point Likert scale was performed. Two-way repeated measures ANOVA tested for differences between treatment groups and changes over time. Results We created a preclinical ex vivo ILP model to simulate the effects of DSM-TPCE. In histopathological analysis, only two specimens, treated with only DXO, showed an increase in parenchymal damage over time. No significant effect of time (3.3%, p = 0.305) or group (23.3; p = 0.331) was identified. Within the lung tissue, the DXO concentration ranged from 205 to 1,244 ng/g. No significant effects could be detected regarding different treatment groups (4.9% of total variation, p = 0.103). Conclusion In an ex vivo ILP model using human lung lobes, the physiological effects of DSM-TPCE with DXO could be tested. Neither increased DXO concentrations in lung tissue nor histopathological changes indicating early lung toxicity were observed. Relevance statement An ex vivo ILP model using human lung specimens did not show any signs of early lung toxicity after transpulmonary chemoembolization with DXO. These results support further evaluation of DSM-TPCE in phase I/II trials. Key Points Transpulmonary chemoembolization can be investigated in an ex vivo ILP model. DSM did not increase DXO in normal lung tissue. DSM did not increase parenchymal toxicity compared to the control groups. Graphical Abstract

Purpose: Moderate traumatic injuries and lung contusions are considered a clear exclusion criterion for ex-vivo lung perfusion (EVLP) by most transplant centers. This is due to the presumed poor performance during perfusion, which is caused by increased capillary leak and resulting pulmonary edema.

Background:Emphysema patients, who are candidates for lung volume reduction surgery (LVRS) usually present with an extensive smoking history and thus have an increased risk for lung. The incidence of pulmonary nodules in emphysematous lungs is high. We therefore aimed to analyse the incidence and histological findings of pulmonary nodules in our LVRS program.Methods:We conducted a retrospective review of all patients who underwent LVRS between 2016 and 2018. Data concerning preoperative workup, 30 days mortality and histopathological findings analysed.Results:Between 2016 and 2018, LVRS was performed in 66 patients. In 18 (27%) a nodule was found in the preoperative computed tomography (CT) scan. Histological findings revealed in two cases squamous cell lung cancer. In two other cases, histopathological findings revealed an anthracotic intrapulmonary lymph node. In eight cases, a tuberculoma was found with a positive culture in one case. The other six histopathological findings were hamartoma, granuloma or sequelae of pneumonia.Conclusions:Malignancy was found in 11.1% of patients presenting with a nodule in preoperative LVRS workup. The relative risk of lung cancer in emphysema patients is increased and if LVRS criteria are fulfilled surgical resection of a pulmonary nodule is a meaningful way to verify the histology.

The use of Isolated lung perfusion (ILP), combined with medical imaging modalities such as positron emission tomography-computed tomography (PET/CT), provides real-time visualization of tumors in ventilated and perfused vital lung tissue. This experiment intends to show the feasibility and benefits of using ILP combined with PET/CT imaging. Following lung surgery on a 49-year-old male, his left lower lobectomy specimen, which held a typical carcinoid tumor, was preserved on normothermic ILP. Gallium-68-Edotreotide ([68Ga]-DOTATOC) was administered into the ILP circuit, and dynamic emission data from PET/CT was acquired. ILP was carried out for 120 minutes. Near physiologic gas exchange and glucose metabolism were preserved throughout the experiment. The time activity curves (TAC) of 5 different volumes of interest (VOI) showed notable differences in tracer uptake over time. The peripheral area of the carcinoid exhibited delayed but high somatostatin receptor agonist uptake compared to the surrounding parenchyma and the intrapulmonary artery. However, the central area of the carcinoid showed very low [68Ga]-DOTATOC uptake. This experiment demonstrates the potential of ILP combined with PET/CT for kinetic modeling in experimental nuclear medicine imaging. By providing visualization of tracer uptake in perfused lung tissue, this model could potentially improve our understanding of tumor physiology and molecular imaging.

Background and Objective: Extracorporeal life support (ECLS) is widely used in patients with severe respiratory or cardiocirculatory failure.The most commonly used extracorporeal membrane oxygenation (ECMO) modes are veno-venous (V-V) and veno-arterial (V-A) ECMO, which can both be achieved by various types of vascular cannulation.Within the scope of tracheobronchial surgery, intraoperative ECLS may occasionally be necessary to provide sufficient oxygenation to a patient throughout a procedure, especially when conventional ventilation strategies are limited.Additionally, V-A ECMO can provide cardiopulmonary support in emergencies and in cases where hemodynamic instability can occur.Methods: This narrative literature review was carried out to identify the use and the specifics of ECLS in airway surgery over the last years.Data from 168 cases were summarized according to the indication for surgery and the mode of ECLS (V-V, V-A). Key Content and Findings:The most common tracheobronchial pathologies in which support was needed were: primary malignant disease of the airways, malignant infiltration, tracheal stenosis, injury of the airway, and congenital airway disease.With increasing experience in ECLS, the number of reported cases performed with intraoperative ECLS increased steadily over the last decade.Conclusions: A trend favoring the use of V-V ECMO over V-A ECMO was identified.These approaches should now be considered indispensable tools for managing challenging surgical cases.

Die Lungentransplantation (LuTx) ermöglicht nicht nur eine Verlängerung der Lebensdauer für hoch selektionierte Patienten mit benignen Lungenerkrankungen im Endstadium (z. B. Lungenfibrose, COPD, zystische Fibrose, α1-Antitrypsinmangel und pulmonalarterielle Hypertonie), sondern auch eine wesentliche Verbesserung der Lebensqualität. Aktuell sind fast 80 % aller weltweiten Eingriffe bilaterale Lungentransplantationen. In Deutschland werden jährlich in etwa 400 Patienten in wenigen spezialisierten Zentren lungentransplantiert. Ein grundlegendes Verständnis bezüglich der Indikationen und des peri- und postoperativen Managements dieser Patienten sollte jeder Thoraxchirurg haben, um auch Therapiealternativen entsprechend einordnen zu können.

Background Transpulmonary embolisation (TPE) using degradable starch microspheres (DSM) is a potential approach to treat pulmonary metastases. However, there is a paucity of detailed information on perfusion dynamics. The aim of this study was to establish a human ex vivo isolated lung perfusion (ILP) model to observe and evaluate the effects of DSM-TPE in a near-physiologic setting. Methods ILP was carried out on six surgically resected lung lobes. At baseline, computed tomography (CT), including CT perfusion imaging (CTPI), and histopathological sampling were performed (t30). DSM-TPE was initiated and increased stepwise (t45, t60, t75, and t90) to be followed by CT imaging, histopathological sampling, and pulmonary arterial pressure (PAP). After the last assessment (t90), alpha-amylase was injected into the pulmonary artery to allow for DSM hydrolysation and two additional assessments (t105; t120). Histopathological specimens were evaluated using a semiquantitative ordinal score. CTPI was used for time to peak (TTP) analysis. Results After DSM administration, PAP and TTP increased significantly: PAP slope 95% confidence interval (CI) 0.104-0.483, p = 0.004; TTP t30 versus t45, p = 0.046. After the addition of alpha-amylase, functional parameters reverted to values comparable to baseline. In histopathological samples, embolisation grades increased significantly until t90 (slope 95% CI 0.027-0.066, p < 0.001) and decreased after addition of alpha-amylase (slope 95% CI -0.060-0.012, p = 0.165), Conclusions The ILP model demonstrated successfully both the physiologic effect of DSM-TPE on human lungs and its reversibility with alpha-amylase. Thus, it can be used as a near-physiologic preclinical tool to simulate and assess later clinical approaches.

Hintergrund Die Behandlung von trachealen Pathologien erfordert eine multidisziplinäre Indikationsstellung, Therapie und Nachsorge um eine bestmögliche Versorgung der Patienten zu gewährleisten. Die chirurgischen Resektionstechniken wurden kürzlich bei komplexen Krankheitsbildern (insbesondere des laryngotrachealen Überganges) um neuere Verfahren erweitert. In Anbetracht eines heterogenen Patientengutes und Verfahren mit unterschiedlicher Komplexität zielt diese Studie darauf ab eine Risikostratifizierung hinsichtlich der postoperativen Ergebnisse zu ermöglichen.

Abstract Adenoid cystic carcinomas are the second most common entity of tracheal malignancies, which have an overall incidence as low as only 0.2 in 100,000 persons per year. We present the case of a 64-year-old man with a histologically confirmed adenoid cystic carcinoma who sequentially underwent 18F-FDG PET/CT and 68Ga-PSMA-11 PET/CT within 1 day for staging 3 days before surgical resection of the tumor. Immunohistochemistry revealed PSMA expression of the tumor corroborating the PSMA PET findings.

Hintergrund Lung volume reduction surgery (LVRS) is an established therapeutic approach for patients with severe lung emphysema to improve symptoms and quality of life. The impact of pulmonary hypertension (PH) on outcome after LVRS is still not sufficiently investigated. Our general approach to LVRS was switched from a unilateral staged approach to a bilateral procedure. Thus, we firstly aimed to assess the influence of unilateral versus bilateral surgery and secondly of preoperative PH on functional outcome after LVRS.

Hintergrund Die transpulmonale Embolisation (TPE) mit abbaubaren Stärkemikrosphären (DSM) könnte eine Behandlungsmodalität für inoperable Lungenmetastasen darstellen. Ziel dieser Studie war es, in einem präklinischem nah-physiologischem Modell mittles isolierter Lungenperfusion (ILP) humaner Lungenlappen ein solches Vorgehen zu erproben.

Background Tracheal and laryngotracheal surgery provides both excellent functional results and long-term outcomes in the treatment of tracheal stenosis. Consequently, challenging re-resections are rarely necessary. The purpose of this study was to compare the outcome of (laryngo-)tracheal re-resection and surgery after bronchoscopic interventions with that of primary surgery. Methods Patients undergoing resection for benign tracheal stenosis at our center between 1/2016 and 4/2020 were included. Perioperative characteristics and functional outcomes of patients were used for statistical analysis. Results Sixty-six patients who underwent (laryngo-)tracheal resection were included (previous resection [A=6], previous stent [B=6], previous bronchoscopic intervention w/o stenting [C=19], untreated [D=35]). Baseline parameters were largely comparable between groups with exception from group B that had significantly worse lung function. Group A necessitated more complex reconstructions (end-to-end: n =1: 17%| cricotracheal n =2: 33%| cricotracheal with mucosectomy n =2: 33%| laryngoplasty: n =1: 17%) than patients in group D (end-to-end n =21: 60%| cricotracheal n =14: 40%). Postoperative outcomes were comparable throughout groups (intensive care unit: 1[1-18] days; hospital stay: 8[5-71] days). Anastomotic complications were higher after previous stenting (A: 0%; B: 33.3%; C: 10.5%; D: 2.9%; B/D p =0.008| surgical revisions: A: 16.7%; B: 33.3%; C: 0%; D: 5.7%; B/D, p =0.035). Overall, postoperative lung function was significantly better (forced expiratory volume in 1 second: 63%24 vs. 75%+/- 20; p =0.001 | PeakEF 3.3 +/- 1.9 vs. 5.0 +/- 2.2L; p =0.001). No 90-day mortality was observed in any group. Median follow-up was 12(1-47) months. Conclusion In carefully selected patients treated in a specialized center, tracheal or laryngotracheal resection after previous tracheal interventions provides comparable outcome to primary surgery.

OBJECTIVES:Pulmonary retransplant (ReTx) is considered a controversial procedure. Despite literature reporting outcomes following ReTx, limited data exist in recipients bridged to their ReTx on extracorporeal life support (ECLS). The goal of this study was to investigate the outcomes of recipients bridged to a first-time ReTx by ECLS. METHODS:We performed a retrospective multicentre cohort analysis from 10 centres in Europe, Asia and North America. The primary outcome was overall survival. Risk factors were analysed using Cox regression models. RESULTS:ECLS as a bridge to a first-time ReTx was performed in 50 recipients (ECLS-ReTx). During the study period, 210 recipients underwent a first-time ReTx without bridging on ECLS (regular-ReTx) and 4959 recipients had a primary pulmonary transplant (index-Tx). The overall 1-year (55%) and 5-year (29%) survival was significantly worse for the ECLS-ReTx group.Compared to the index-Tx group, the mortality risk was significantly higher after ECLS-ReTx [hazard ratio 2.76 (95% confidence interval 1.94-3.91); P < 0.001] and regular-ReTx [hazard ratio 1.65 (95% confidence interval 1.36-2); P < 0.001].In multivariable analysis, recipient age ≥35 years, time interval <1 year from index-Tx, primary graft dysfunction as transplant indication, venoarterial-extracorporeal membrane oxygenation and Zurich donor score ≥4 points were significant risk factors for mortality in ECLS-ReTx recipients. CONCLUSIONS:Recipients for ECLS-ReTx should be carefully selected. Risk factors, such as recipient age, intertransplant interval, primary graft dysfunction as transplant indication and type of ECLS should be kept in mind before bridging these patients on ECLS to ReTx.

Objective: The impact of previous lung volume reduction surgery (LVRS) or endoscopic lung volume reduction (ELVR) on lung transplantation (LuTX) remains unclear. This study assesses the risk of previous lung volume reduction on the outcome of a later LuTX. Methods: Patients suffering from emphysema who underwent bilateral LuTX were included in this multicenter analysis. Study groups were defined as: previous LVRS, previous ELVR, controls. Imbalances were corrected by coarsened exact matching for center, gender, age, diagnosis, and BMI. A comparative analysis of intraoperative characteristics, perioperative outcome and long-term survival was performed. Results: 615 patients were included (LVRS = 26; ELVR = 60). Compared to controls, LVRS patients had a higher rate of postoperative ECMO (15.4 vs. 3.9%; p = 0.006), whereas ELVR patients suffered more often from wound infections (8.9% vs. 2.5%; p = 0.018). Perioperative outcome, duration of ventilation, ICU stay, and hospital stay were comparable between groups. Bacterial colonization of the airway differed significantly between both LVR groups and controls in pre- and post-LuTX cultures. Survival was not impacted (1-/3-/5-year survival for LVRS: 92.3%/85.7%/77.1%; controls: 91.3%/82.4%/76.3%; p = 0.58 | ELVR: 93.1%/91%/91%; controls 91.2%/81.7%/75.3%; p = 0.17). Conclusion: Lung volume reduction does not impact short and long-time survival after bilateral LuTX. Due to differences in airway colonization after LVR, caution to prevent infectious complications is warranted.

Hintergrund Intraoperative extracorporeal membrane oxygenation (ECMO) enables lung resections that are otherwise impossible or difficult on one-lung ventilation but also improves exposure for complex airway surgery. Outside the transplant setting, ECMO support during surgery is still considered rare. We therefore describe our single-center experience.