Impact of Difficult Lung Transplantation on Short-Term and Long-Term Survival

•Difficult lung transplantation adversely affects short-term outcomes.•Difficult lung transplantation does not worsen long-term survival.•Modifier-22 is a reasonable marker to identify difficult lung transplants. Lung transplantation (LTx) is a complex operation; however, certain factors can make LTx even more challenging. A difficult LTx could adversely affect immediate and long-term outcomes. We investigate the potential use of Modifier-22 to identify difficult LTx to evaluate postoperative outcomes. A retrospective analysis was performed on patients who had undergone LTx between January 1, 2010, and October 1, 2018, at the University of Washington. Patients undergoing repeat LTx, other solid organ transplantation, and/or with prior major cardiothoracic surgery were excluded. Patients were classified into 2 categories: standard LTx and difficult LTx groups. We examined hospital length of stay (LOS), intensive care unit (ICU) LOS, duration on the ventilator, and 1-, 3-, and 5-year survival. A total of 370 patients were identified, with 268 patients in the standard LTx group and 102 patients in the difficult LTx group. The median LOS, ICU LOS, and duration on the ventilator in the difficult LTx group was 18.0 ± 1.6 days, 6.0 ± 1.2 days, and 2.0 ± 0.9 days compared with 15.0 ± 0.8 days, 4.0 ± 0.7 days, and 1.0 ± 0.3 days in the standard LTx group, respectively (all P < .01). Kaplan-Meier analysis revealed that both groups had similar survival. Modifier-2 can be used to identify challenging LTx. Difficult LTx negatively impacts early postoperative outcomes with longer LOS, ICU LOS, and duration on the ventilator. However, long-term survival was not affected. Clinicians should not view pleural space and anatomical complexities, which are a consequence of the underlying disease, as a risk factor for impaired survival.