Risk Factors and Outcomes of Reintubation Following Combined Heart‐Lung Transplantation

BACKGROUND: Unplanned reintubation after combined heart-lung transplantation (HLT) significantly affects morbidity and mortality, yet national data are limited. We evaluated the incidence, predictors, timing, and outcomes associated with reintubation after HLT. METHODS: We retrospectively reviewed adults undergoing primary HLT in the UNOS registry from January 2004 to September 2024. Patients were stratified by reintubation status (defined as re-established mechanical ventilation (MV) after initial extubation). Propensity matching (1:1) balanced recipient and donor characteristics. Multivariable logistic regression models identified independent risk factors. RESULTS: Among 609 adult HLT recipients, 165 (27.1%) required postoperative reintubation. After 1:1 propensity score matching, 146 patients who were reintubated were compared with 146 patients who were successfully extubated. Reintubation was associated with significantly higher early mortality: 30-day (8.2% vs. 3.4%; p = 0.023), 90-day (11.6% vs. 5.5%; p = 0.030), and 6-month (15.1% vs. 8.2%; p = 0.028) mortality rates were all higher in the reintubated cohort, although long-term survival at 1, 3, and 5 years was similar between groups. Early graft failure was more frequent among reintubated patients at 30 days (5.5% vs. 0.7%; p = 0.018) and 90 days (6.2% vs. 1.4%; p = 0.031), with no significant differences thereafter. Reintubated recipients also demonstrated worse functional recovery at discharge (moderate-to-severe limitation: p = 0.012), longer duration of mechanical ventilation (extubated ≤48 h: 20.6% vs. 41.8%; p = 0.003), markedly prolonged hospital stays (73.4 ± 68.8 vs. 37.7 ± 35.3 days; p < 0.0001), and higher rates of stroke (5.5% vs. 3.4%; p = 0.035) and dialysis (37.7% vs. 20.6%; p = 0.001). CONCLUSIONS: Reintubation after HLT significantly increases morbidity and mortality. Identified predictors provide actionable targets for enhanced perioperative airway management.