Effect of Surgical Exposure on Outcomes in BLTx: Insight From the International ECLS Registry

Based on the international multicenter ECLS in Lung Transplantation Registry, this study compared the three surgical approaches to bilateral lung transplantation (BLTx) (clamshell, n=451; isolated bilateral thoracotomies, n=624; and median sternotomy, n=125) in 1,200 adults transplanted at 12 high-volume centers between 2016 and 2024. Using three separate 1:1 propensity score–matched comparisons, the study showed that, relative to the clamshell incision, isolated bilateral thoracotomies were associated with less severe primary graft dysfunction, faster recovery, and superior unadjusted graft survival at one and three years (91 percent vs 86 percent and 74 percent vs 64 percent; p=0.007) that narrowed by five years. While sternotomy carried more graft dysfunction and pneumonia, survival was comparable to thoracotomies. These associations attenuated after multivariable adjustment and support tailoring the incision choice to recipient risk, procedural complexity, and institutional volume expertise.