Introduction As of April 2021, 78 lung transplants (LTx) were performed for a diagnosis of COVID-19: 50 for COVID-19 ARDS and 28 for pulmonary fibrosis. Bilateral LTx has been recommended as many patients develop significant pulmonary hypertension. Additionally, native lung explants may include cavitary areas of pneumonia, which could serve as a nidus for infection. Single LTx (SLTx) can be considered in patients who have chronic pulmonary fibrosis secondary to COVID-19 with a short window to receive a transplant, or who would otherwise be considered for a single lung. There have been no published cases of a single lung transplant for COVID-19 pulmonary fibrosis. We present a case of a patient with pulmonary fibrosis from COVID-19 who underwent SLTx. Case Report A 70yo male with O+ blood type was hospitalized 8/2020 to 10/2020 with COVID-19 pneumonia, treated with Remdesivir and Tocilizumab. He had hypoxia but never required intubation. His course was complicated by bilateral pneumothoraces requiring chest tubes. He developed pulmonary fibrosis requiring 6 L of oxygen at rest. CT scan of his chest showed multifocal, peripheral prominent ground glass opacities and interlobal septal thickening with traction bronchiectasis. Ventilation-perfusion scan demonstrated 22% perfusion to the left lung and 78% to the right lung. Right heart catheterization showed pulmonary artery pressures of 36/12 mmHg. His pulmonary function test was suggestive of restrictive disease (FEV 0.81 L [30%], FVC 0.96 L [27%], and FEV1/FVC 85%) that had worsened over time. He was presented at multidisciplinary review board with recommendation to list for left SLTx, which was activated August 2021. The patient was admitted in September 2021 and underwent left single lung transplant via left anterolateral thoracotomy, off cardiopulmonary bypass. Total ischemia time was 3:54. Explant pathology showed end stage pulmonary fibrosis. The patient was extubated on postoperative day 1 with an uneventful postoperative course. He was discharged to skilled nursing facility on postoperative day 26 for rehabilitation. Summary SLTxp is safe and feasible for COVID-19 related pulmonary fibrosis in well-selected patients who have a short window to receive a transplant.

Purpose Meticulous patient selection in lung transplantation remains a critically important driver of successful outcomes. We had previously created a validated risk-stratification model to aid in the pre-transplant assessment of potential recipients using only preoperative recipient data. We sought to assess the value of our model by comparing outcomes before and after the implementation of the model. Methods Data from lung transplant recipients at a single transplant institute from 2009-2018 were extracted from the UNOS database. Patients were divided into cohorts from before the implementation of the risk model (2009-2014) and after the implementation of the risk model (2015-2018). Patient and graft survival were assessed with Kaplan-Meier survival curves and compared using Cox proportional-hazards models. Results We analyzed 907 patients who underwent lung transplantation between 2009 and 2018, comparing the cohort between 2009 and 2014 ( n=633), before implementation of our risk model, to the cohort transplanted between 2015 and 2018 (n=274), after implementation of our risk model. Three-year survival was significantly different between cohorts (61.4% vs 77.7%, p<0.001) (Figure 1). Survival was also significantly different within the moderate-risk group between cohorts (n=253 vs n=136, 65.0% vs 75.8%, p=0.01). Differences in survival were most pronounced in the high-risk group between cohorts (n=166 vs n=47, 44.1% vs 79.5%, p<0.001). Stratification of recipients into low-, moderate- (HR 1.45, CI 1.01-2.08, p=0.01), and high-risk cohorts (HR 2.52, CI 1.70-3.73, p<0.001) continued to demonstrate significant differences in mortality. Conclusion Our lung transplant recipient risk-stratification model provides a valuable pre-transplant assessment tool, with significantly improved survival in our patient population after its implementation. In reassessing the model and its components, it continues to demonstrate effective discrimination of patients by risk of mortality.

Rationale: Growing literature on the coronavirus disease 2019 (COVID-19) suggests that obesity (BMI > 30 kg/m2) is a strong risk factor for increasing disease severity, hospitalization and admission to the intensive care unit (ICU). In such critically ill patients with acute respiratory distress syndrome (ARDS), the use of extracorporeal membrane oxygenation (ECMO) can serve as salvage therapy. The Extracorporeal Life Support Organization (ELSO) COVID-19 ECMO registry reports that 49% of its patients were classified as obese as of 12/01/2020. However, the morbidity and mortality outcomes of this subgroup remains unclear. As such, this high-risk population merits further examination. Methods: We identified adult COVID-19 ARDS patients who were candidates for either veno-venous ECMO or veno-arterial ECMO between March 13, 2020 and August 31, 2020. The eligibility for ECMO was selected based on our institutional algorithm and the EOLIA Trial criteria (except for high BMI cutoff). Patients were divided into two groups, obese (BMI > 30 kg/m2) and non-obese (BMI < 29.9 kg/m2). We compared the pre-cannulation characteristics including time elapsed between admission to ECMO, intubation to ECMO and respiratory indices. We then examined length on ECMO, ICU or hospital length of stay and disposition. Fisher's exact and Mann-Whitney U tests were used to analyze categorical and continuous data. Results: We identified a total of 41 patients, 33 (80.5%) were obese and 8 (19.5%) were non-obese [Table 1]. The average age of the obese and non-obese groups was 47.8 years and 55.5 years respectively. The median BMI was 39.85 kg/m2 (IQR: 35.63, 43.00) in the obese group and 29.05 kg/m2 (IQR: 25.35, 29.39) in the non-obese group (p <0.00001). There was no difference in precannulation characteristics between the groups. In terms of timelines, the obese group was borderline significant with regards to more time elapsed between admission to ECMO (p = 0.058), however, no other significant changes were noted. The ICU length of stay was lower in the obese group with median runtime of 22 days versus 35.5 days (p = 0.029). There was no statistically significant difference in mortality (p = 0.43) or dispositions between the two groups. Conclusion: In our study, the obesity group did not have worse outcomes than the non-obese group. This should encourage consideration of ECMO in carefully selected obese patients with severe ARDS from COVID-19.

The use of Left Ventricular Assist Devices (LVADs) has become increasingly popular in patients with Class IIIb and IV heart failure. In the clinical setting, we have observed variation in quality of life (QOL) and subjective prognostic outlook between Bridge-to-Transplant (BTT) and Destination Therapy (DT) patients. However, differences in QOL between these two treatment groups have not been formally established. This study evaluated QOL among BTT and DT recipients of LVADs. We hypothesized that DT patients have improved quality of life compared to BTT patients. A retrospective chart review was conducted to evaluate Minnesota Living with Heart Failure Questionnaire (MLHFQ) scores obtained from LVAD recipients as a standard of care from 2010 to 2015. The MLHFQ is comprised of 21 questions; scores range from 0-105, with a lower score indicating better quality of life. MLHFQ scores collected at baseline (prior to LVAD implant), 3 and 6 months post-LVAD implant were evaluated for the purpose of this study. Patients who did not complete the MLHFQ at all three time-points were excluded from the analyses. A two-sample t-test assuming unequal variances was used to analyze differences in MLHFQ scores between BTT and DT patients at baseline, 3 and 6 months. Seventeen BTT patients and five DT patients had complete data at each time-point. DT patients had similar MLHFQ scores at baseline compared to the BTT group (68±14.5 DT vs. 75.2±18.4 BTT, p=0.19). MLHFQ scores improved in both groups at 6 months: -16.6±14.4 DT vs. -39.9±17.3 BTT, however, the DT patient scores improved to a greater degree over 6 months (rate of score reduction Baseline-6 months: 51.4±19.5 points DT v. 35.3±10.6 points BTT at 6 months, p=0.016). We observed that DT patients have improved QOL compared to BTT patients 6 months post-LVAD implant. Although further research is needed to confirm these findings among a larger study population, current patient support and education materials available to BTT patients should be evaluated for use of interdisciplinary strategies to improve QOL in this population.

Successful long-term LVAD support mandates device design that is durable and free from mechanical failure. We evaluated the incidence and cause of major device malfunctions and pump replacements in the HeartMate II LVAD (HM2) clinical trial.

Determine the prevalence, etiology of infection, and attempt to develop a method of pseudomonas prophylactic therapy for HMII patients at our institution.

It has not been shown if continuous flow LVADs can provide adequate support for larger patients as compared to pulsatile flow LVADs, especially in the early postop period.

Continuous flow left ventricular assist devices (LVAD) are a small quiet rotary blood pumps for circulatory support in advanced heart failure patients. The HeartMate II LVAD (HM2) is being evaluated in clinical trials for bridge to transplantation (BTT) and for destination therapy. We report on the updated results and one year outcomes from the BTT study.

Left ventricular assist devices (VAD) reduce pulmonary vascular resistance (PVR) in severe heart failure. The Heartmate II (HMII), a continuous axial flow pump improves the clinical status of patients awaiting transplantation. Our aim was to non invasively assess the HMII's effect on PVR and right heart function in view of the risks associated with right heart catheterisation in VAD patients.

Purpose: To evaluate the hypothesis that the use of small axial flow LVAD systems in bridge to transplant patients results in decreased length of stay during the post implant hospitalization period compared to larger pulsatile devices.