Outcomes and utilization of organs from hypoxemic donors in heart-lung transplantation: an observational study
Michael Keller1
, Ye In Christopher Kwon1
, Joshua Pei2, Matthew Ambrosio1, Motaz Al-Yafi1, Vipul Patel3, Rachit D. Shah1, Vigneshwar Kasirajan1, Zubair A. Hashmi1
Contributions: (I) Conception and design: M Keller, YIC Kwon; (II) Administrative support: V Kasirajan, V Patel, ZA Hashmi; (III) Provision of study materials or patients: M Keller, YIC Kwon, M Ambrosio; (IV) Collection and assembly of data: M Keller, YIC Kwon, M Ambrosio; (V) Data analysis and interpretation: M Keller, J Pei, YIC Kwon, M Al-Yafi, V Kasirajan, V Patel, ZA Hashmi; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
Background: Prior studies have found that hypoxemic donor lungs, measured as PaO2/FiO2 (P/F) ≤300 mmHg, do not confer adverse outcomes in lung transplant. However, this has not been investigated since United Network for Organ Sharing (UNOS) modified the composite allocation score [Lung Allocation System (LAS)] system in 2017. This also remains unknown in heart-lung transplantation (HLT). Here, we analyze the utilization and outcomes of hypoxemic donor lungs in HLT.
Methods: Using the UNOS database, we identified all adults (>18 years old) undergoing HLT between 2010 and 2024. Recipients were stratified by hypoxemic (P/F ≤300 mmHg) and normal donor (P/F >300 mmHg). We further stratified these HLT recipients into pre-2017 (Era 1) and post-2017 (Era 2) LAS modification. Baseline characteristics were compared between cohorts. Kaplan-Meier method was used to compare 30-day, 1-, and 3-year survival. Cox regression models were used to assess the impact of donor hypoxemia, eras, and other donor factors on overall survival.
Results: A total of 439 patients underwent HLT (40 hypoxemic vs. 399 normal donors). Hypoxemic donor utilization has remained low between eras (21 cases in Era 1 vs. 19 cases in Era 2; P=0.20). Recipients of hypoxemic donors were older (P=0.007). Hypoxemic donors had increased rates of abnormal chest X-ray (P=0.001) and bronchoscopy results (P=0.02) compared to normal donors. There was no difference in survival between recipients of hypoxemic and normal donor lungs (P=0.08), regardless of the era (P=0.15). Hypoxemic donors had 90.5%, 70.6%, and 65.6% survival in Era 1, compared to 88.9%, 75.4%, and 40.2% survival in Era 2 at 30-day, 1-, and 3-year intervals, respectively. Neither donor hypoxemia [hazard ratio (HR) 0.64, P=0.07] nor Era 1 (HR 1.2, P=0.30) were associated with survival outcomes.
Conclusions: Since 2017, hypoxemic donors continue to be underutilized in HLT despite comparable long-term outcomes to normal donors. However, due to the small number of patients receiving hypoxemic donor lungs in HLT, further studies are warranted to better interpret these results. Additionally, implementation of the LAS allocation system has not impacted survival of these transplants.
Keywords: Heart-lung transplantation (HLT); respiration disorders; hypoxia
Received: 28 November 2025; Accepted: 20 April 2026; Published online: 27 April 2026.
doi: 10.21037/ccts-2025-1-69
Highlight box
Key findings
• Usage of organs from hypoxemic donors is not associated with decreased short- or long-term survival in combined heart-lung transplantation (HLT) recipients.
• Updated allocation systems in the United States have not led to a change in utilization of these hypoxemic organs.
What is known and what is new?
• While updated allocation processes have led to decreased waitlist mortality and increased one-year survival, finding ways to expand the donor pool and provide increased but equitable access to organs is of utmost importance.
• This manuscript demonstrates comparable survival for HLT recipients of organs from hypoxemic donors, providing an avenue for increased access to extended criteria donors.
What is the implication, and what should change now?
• Donor hypoxemia is not associated with decreased survival in HLT recipients, suggesting wider utilization of these donors is safe and feasible. However, further studies remain needed as hypoxemic donors become more utilized.
Introduction
Combined heart-lung transplantation (HLT) is primarily indicated for congenital heart disease, acquired heart disease with pulmonary hypertension or intrinsic lung disease (1,2). In patients with end stage disease, HLT is frequently the last resort, however, access to transplantation has been affected by changing allocation systems and differing criteria for extended criteria donors. Nationally, lung allocation was governed by the Lung Allocation System (LAS) as of 2017 and was recently updated to the Composite Allocation Score (CAS) in 2023. Both systems reduced wait-list mortality and while the LAS prioritized medical urgency and geographic location, the CAS was implemented to increase equity amongst recipients (3-5). This has resulted in improved access for marginalized groups, and increased one-year survival despite increased lung ischemic times and travel distances (5,6). Additionally, heart allocation has been changed in 2018 to allow for prioritization of critically ill patients and has led to improved waitlist outcomes and decreased early post-transplant mortality (7-9).
In addition to the implementation of the CAS system, increasing lung access for transplant candidates remains a multifactorial problem. Currently, lung supply is primarily comprised from donations after brain death (DBD), which contributed 89.8% of lung transplants in the United States in 2023 (10). Expansion of the donor pool has recently focused on increasing donation after cardiac death (DCD), which while increasing, still faces logistical and ethical dilemmas (10,11). Other avenues for expansion have included the use of ex vivo lung perfusion (EVLP) and extended donor criteria, referring to donor lungs not meeting standard transplantation criteria (12,13). One standard criterion that has seen flexibility is the arterial partial pressure of oxygen/fractional inspired oxygen ratio (P/F ratio). Typically, P/F ratios <300 mmHg are considered extended donors (14).
Complications of combined HLT mirror those seen in isolated heart and lung transplantation; however, mortality is largely driven by complications related to lung transplantation. Early complications include primary graft dysfunction (PGD), acute rejection and infections (2,15). Chronic lung allograft dysfunction (CLAD), chronic rejection, and renal dysfunction are all associated with long-term complications (2,15). However, usage of lungs from donors with P/F <300 mmHg has not been shown to be associated with changes in PGD, pulmonary function, and recipient survival (16).
While this lack of adverse effects has been shown in isolated lung transplantation; the effects of hypoxemic donors have not been explored in HLT. Thus, this study aims to examine the relationship between P/F ratio on combined HLT both before and after implementation of the LAS. We present this article in accordance with the STROBE reporting checklist (available at https://ccts.amegroups.com/article/view/10.21037/ccts-2025-1-69/rc).
Methods
Study population
The United Network for Organ Sharing (UNOS, https://hrsa.unos.org/data/view-data-reports/request-data/) standard database was utilized to identify all adults (>18 years old) undergoing HLT between January 1st, 2010, and April 30th, 2024. Patients were excluded if follow-up data beyond 6 months was not available. Recipients were stratified by hypoxemic donor (P/F ≤300 mmHg) and normal donor (P/F >300 mmHg). They were further stratified by date of transplantation: Era 1 was prior to November 24th, 2017 and Era 2 was after November 24th, 2017 (Figure 1).
Statistical analysis
Primary outcome was 12- and 36-month survival, stratified by donor hypoxemia and era of transplant. Secondary outcomes include acute rejection, post-transplant length of stay, need for dialysis, and incidence of post-operative stroke or airway dehiscence. Continuous variables were reported as mean ± standard deviation (SD) and categorical variables were reported as number (%). Comparisons between groups utilized χ2, Wilcoxon rank-sum, or Fisher’s exact tests as appropriate. Survival was measured using the Kaplan-Meier method and compared with log-rank tests. In addition to era and P/F ratio, variables with significant difference on univariate analysis were compared with a Cox-proportional hazard regression model to assess for independent predictors of survival. Results were reported as adjusted hazard (HR) or odds (OR) ratios with 95% confidence intervals (CIs). All statistical analyses were conducted using SAS (version 9.4; SAS Inc., Cary, NC, USA). All P values were based on two-sided statistical tests, with significance set at P<0.05.
Ethical consideration
The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study utilized deidentified data and was thusly exempt from the Virginia Commonwealth University Institutional Review Board, and informed consent was waived.
Results
Baseline recipient and donor characteristics
A total of 439 patients who underwent combined HLT were identified with 40 patients receiving organs from donors with a P/F ratio ≤300 mmHg (9.1%). One hundred eighty-four of HLT recipients were in Era 1 (42%) and 255 recipients were in Era 2 (58%); however, 21 (53%) of the hypoxemic donor transplants took place during Era 1, while 19 (48%) took place in Era 2 (P=0.20) (Table 1). Patients receiving hypoxemic organs were older (50.4 vs. 44.7 years, P=0.007) but did not differ in sex (P=0.10), race (P=0.50), or body surface area (BSA) (P=0.20). Hypoxemic donors had significantly higher rates of abnormal chest X-rays (83% vs. 56%, P=0.001) and abnormal bronchoscopy (38% vs. 21%, P=0.02).
Table 1
| Characteristics | Overall (N=439) | Hypoxemic (N=40) | Normal oxygenation (N=399) | P value |
|---|---|---|---|---|
| Recipient | ||||
| Age (years) | 45.25 (13.12) | 50.43 (12.00) | 44.73 (13.13) | 0.007 |
| Sex | 0.10 | |||
| Female | 219 [50] | 15 [38] | 204 [51] | |
| Male | 220 [50] | 25 [63] | 195 [49] | |
| Race | 0.50 | |||
| White | 246 [56] | 26 [65] | 220 [55] | |
| African American | 94 [21] | 9 [23] | 85 [21] | |
| Asian | 31 [7.1] | 2 [5.0] | 29 [7.3] | |
| Hispanic/Latino | 67 [15] | 3 [7.5] | 64 [16] | |
| Other/unknown | 1 [0.2] | 0 [0] | 1 [0.3] | |
| Recipient diabetes | 76 [17] | 10 [26] | 66 [17] | 0.20 |
| BMI (kg/m2) | 0.70 | |||
| ≤30 | 382 [87] | 34 [85] | 348 [87] | |
| >30 | 57 [13] | 6 [15] | 51 [13] | |
| BSA (m2) | 1.78 (0.24) | 1.83 (0.28) | 1.77 (0.24) | 0.20 |
| Blood type | 0.50 | |||
| Type A | 173 [39] | 15 [38] | 158 [40] | |
| Type B | 73 [17] | 8 [20] | 65 [16] | |
| Type AB | 18 [4.1] | 2 [5.0] | 16 [4.0] | |
| Type O | 172 [39] | 14 [35] | 158 [40] | |
| Cigarette usage | 144 [33] | 15 [38] | 129 [33] | 0.50 |
| Status during Era 1 | 0.40 | |||
| Status 1 | 1 [0.5] | 0 [0] | 1 [0.6] | |
| Status 1A | 60 [30] | 8 [35] | 52 [30] | |
| Status 1B | 62 [31] | 4 [17] | 58 [33] | |
| Status 2 | 76 [38] | 11 [48] | 65 [37] | |
| Status during Era 2 | 0.30 | |||
| Status 1 | 50 [21] | 2 [12] | 48 [22] | |
| Status 2 | 54 [23] | 3 [18] | 51 [23] | |
| Status 3 | 32 [13] | 5 [29] | 27 [12] | |
| Status 4 | 51 [21] | 2 [12] | 49 [22] | |
| Status 5 | 53 [22] | 5 [29] | 48 [22] | |
| LVAD at transplant | 11 [2.5] | 2 [5.1] | 9 [2.3] | 0.30 |
| ECMO at transplant | 97 [22] | 8 [20] | 89 [22] | 0.70 |
| Intra-arterial balloon pump at transplant | 21 [4.8] | 1 [2.6] | 20 [5.1] | 0.70 |
| Donor | ||||
| Donor age (years) | 32.45 (11.93) | 32.45 (13.53) | 32.45 (11.78) | >0.90 |
| Donor LVEF (%) | 61.38 (6.82) | 62.23 (7.74) | 61.30 (6.73) | 0.50 |
| Ischemic time (hours) | 3.78 (1.02) | 3.77 (1.09) | 3.78 (1.01) | >0.90 |
| Abnormal chest X-ray | 254 [58] | 33 [83] | 221 [56] | 0.001 |
| Abnormal bronchoscopy | 94 [22] | 14 [38] | 80 [21] | 0.02 |
| Era | 0.20 | |||
| Era 1 | 184 [42] | 21 [53] | 163 [41] | |
| Era 2 | 255 [58] | 19 [48] | 236 [59] | |
| Donor distance to transplant (m) | 195.71 (187.11) | 167.40 (173.42) | 198.55 (188.39) | 0.30 |
| Ex vivo perfusion | 2 [0.5] | 0 [0] | 2 [0.5] | >0.90 |
Data are presented as mean (standard deviation) or n [%]. Era 1: pre-2017; Era 2: post-2017. BMI, body mass index; BSA, body surface area; ECMO, extracorporeal membrane oxygenation; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction.
Survival and perioperative outcomes
When examining 1-month, 1- and 3-year survival, no statistically significant differences were seen between hypoxemic and P/F ratio >300 mmHg donors (P=0.08, Figure 2). There was a non-significant trend towards lower survival at 1 month (89.7% vs. 90.6%), 1 year (72.3% vs. 81.9%), and 3 years (56.5% vs. 66.2%) in hypoxemic donors (Table 2). When stratifying by era of transplant, a similar trend can be seen. Overall survival by Kaplan-Meier analysis does not demonstrate a significant difference in post-transplant survival (P=0.15, Figure 2), however, a non-significant trend towards decreased survival in hypoxemic patients can be seen (Table 3). Kaplan-Meier analysis did not demonstrate differences amongst Era 1 (P=0.38) or Era 2 (P=0.12, Figure 3). Despite this trend, cause of death among transplant recipients was similar regardless of donor P/F ratio (Table 4). Rates of acute rejection (7.7% vs. 13%, P=0.30), pacemaker (0% vs. 1.8%, P>0.99), stroke (5.3% vs. 5.1%, P>0.99), dialysis (26% vs. 31%, P=0.50), airway dehiscence (0% vs. 2.6%, P=0.60) and post-transplant length of stay (39.2 vs. 47.4 days, P=0.20) did not differ between donor P/F ratios (Table 5). Adverse effects remained not significantly different when stratified by era of transplantation (Table 6). PGD did not differ between hypoxemic and P/F ratio >300 mmHg donors regarding the cardiac graft (0% vs. 0.3%, P>0.9) or the pulmonary graft (13% vs. 23%, P=0.50).
Table 2
| Survival | Donor P/F ≤300 mmHg (%) | Donor P/F >300 mmHg (%) |
|---|---|---|
| 1 month | 89.74 (80.71–99.79) | 90.60 (87.76–93.53) |
| 12 months | 72.33 (59.01–88.65) | 81.85 (78.05–85.83) |
| 36 months | 56.54 (41.99–76.12) | 66.20 (61.23–71.56) |
Data are presented as survival estimate (95% confidence interval). P/F, PaO2/FiO2.
Table 3
| Survival | Era 1 (%) | Era 2 (%) | |||
|---|---|---|---|---|---|
| P/F ≤300 mmHg | P/F >300 mmHg | P/F ≤300 mmHg | P/F >300 mmHg | ||
| 1 month | 90.48 (78.75–100.00) | 88.34 (83.55–93.41) | 88.89 (75.49–100.00) | 92.19 (88.79–95.72) | |
| 12 months | 70.59 (53.30–93.48) | 80.98 (75.18–87.24) | 75.42 (56.85–100.00) | 82.39 (77.43–87.68) | |
| 36 months | 65.55 (47.77–89.93) | 66.12 (59.22–73.82) | 40.22 (20.04–80.73) | 65.66 (58.52–73.68) | |
Data are presented as survival estimate (95% confidence interval). Era 1: pre-2017; Era 2: post-2017. P/F, PaO2/FiO2.
Table 4
| Characteristic | Overall (N=439) | P/F ≤300 mmHg (N=40) | P/F >300 mmHg (N=399) | P value |
|---|---|---|---|---|
| Recipient cause of death | 158 | 18 | 140 | 0.90 |
| Cardiovascular | 24 [15] | 3 [17] | 21 [15] | |
| Cerebrovascular | 14 [8.9] | 2 [11] | 12 [8.6] | |
| Graft failure | 32 [20] | 2 [11] | 30 [21] | |
| Hemorrhage | 10 [6.3] | 1 [5.6] | 9 [6.4] | |
| Infection | 19 [12] | 2 [11] | 17 [12] | |
| Malignancy | 9 [5.7] | 0 [0] | 9 [6.4] | |
| Organ failure | 25 [16] | 4 [22] | 21 [15] | |
| Other | 5 [3.2] | 1 [5.6] | 4 [2.9] | |
| Pulmonary edema | 20 [13] | 3 [17] | 17 [12] |
Data are presented as n or n [%]. P/F, PaO2/FiO2.
Table 5
| Secondary outcome | Donor P/F ≤300 mmHg | Donor P/F >300 mmHg | P value |
|---|---|---|---|
| Acute rejection | 3 [7.7] | 53 [13] | 0.30 |
| Post-transplant length of stay (days) | 39.22 (35.08) | 47.36 (54.86) | 0.20 |
| Pacemaker | 0 [0] | 7 [1.8] | >0.99 |
| Stroke | 2 [5.3] | 20 [5.1] | >0.99 |
| Dialysis | 10 [26] | 122 [31] | 0.50 |
| Airway dehiscence | 0 [0] | 10 [2.6] | 0.60 |
| Cardiac primary graft dysfunction | 0 [0] | 1 [0.3] | >0.99 |
| Pulmonary primary graft dysfunction | 2 [13] | 49 [23] | 0.50 |
Data are presented as n [%] or mean (standard deviation). P/F, PaO2/FiO2.
Table 6
| Outcomes | Era 1 | Era 2 | P value | |||
|---|---|---|---|---|---|---|
| P/F ≤300 mmHg | P/F >300 mmHg | P/F ≤300 mmHg | P/F >300 mmHg | |||
| Acute rejection | 3 [14] | 25 [15] | 0 [0] | 28 [12] | 0.30 | |
| Post-transplant length of stay (days) | 34.95 (29.29) | 44.13 (56.64) | 44.24 (41.24) | 49.62 (53.58) | >0.99 | |
| Pacemaker | 0 [0] | 3 [1.9] | 0 [0] | 4 [1.7] | >0.99 | |
| Stroke | 1 [5.0] | 9 [5.6] | 1 [5.6] | 11 [4.8] | >0.99 | |
| Dialysis | 4 [20] | 48 [30] | 6 [33] | 74 [32] | 0.70 | |
| Airway dehiscence | 0 [0] | 1 [0.6] | 0 [0] | 9 [3.9] | 0.20 | |
Data are presented as n [%] or mean (standard deviation). Era 1: pre-2017; Era 2: post-2017. P/F, PaO2/FiO2.
Multivariate predictors of mortality
Neither donor hypoxemia (HR 0.64, P=0.07) nor era (HR 1.20, P=0.30) were associated with survival outcomes (Table 7). Only abnormal chest X-ray was associated with increased survival (HR 0.62, P=0.002).
Table 7
| Predictors | Estimate | Confidence interval | P value |
|---|---|---|---|
| P/F >300 mmHg | 0.64 | 0.40–1.04 | 0.07 |
| Era 2 | 1.20 | 0.85–1.70 | 0.30 |
| Abnormal donor chest X-ray | 0.62 | 0.45–0.84 | 0.002 |
| Abnormal donor bronchoscopy | 0.86 | 0.59–1.26 | 0.44 |
| Recipient age | 1.00 | 0.99–1.02 | 0.47 |
Era 2: post-2017. P/F, PaO2/FiO2.
Discussion
As organ transplantation searches for solutions to equitable access and organ utilization, usage of extended criteria donors remains one option necessitating further research. One avenue is the usage of organs from hypoxemic donors. While this has been explored in separate heart and lung transplantation, we report the first national analysis of combined heart and lung transplantation using organs from donors with P/F ratios ≤300 mmHg. We propose that current data supports the usage of organs from donors with P/F ratios ≤300 mmHg as these recipients have similar short and long-term survival outcomes. Furthermore, donor hypoxemia was not independently associated with decreased survival. We also examined temporal trends in usage of these organs, exploring the relationship of their utilization before and after implementation of the 2017 LAS. Era of transplantation was also not independently associated with decreased survival, and survival analysis revealed no significant differences when stratified by era and hypoxemia.
The study benefits from a national database allowing for a larger patient cohort for a procedure with relatively limited occurrence. The primary limitation, however, remains the small numbers of HLT patients receiving organs from hypoxemic donors (40 patients, 9.1%), leading to possible type two errors. Furthermore, the registry-based analyses have several inherent limitations. Practice patterns, particularly when regarding surgeon acceptance of extended criteria organs, vary widely, which may decrease generalizability of these findings. Additionally, it is likely that these hypoxemic donor organs are primarily utilized at select high-volume transplant centers. Volume of transplants performed has been shown to improve outcomes and may obfuscate the findings attributable to the hypoxemia status of the donor, however, this data is only seen in single organ transplants and volume for combined HLT remains low (17).
Brocklebank et al. report 1-year survival rate of 83.9% for HLT patients in 2017-2021 improved from the 63% seen in 2004–2014 reported by Yusen et al. (9,18). We report slightly higher rates with 1 year survival of 90.5% in Era 1 [2010–2017], and 88.9% in Era 2 [2017–2024]. The changes in survival for our Era 1 may be due to the implementation of the first lung allocation score in 2005, leading to decreased waitlist time and increased 1-year survival (19,20). Additionally, our survival rates here are for patients only from non-hypoxemic donors, potentially confounding the comparison.
Mortality in HLT patients is largely driven by post-transplant graft failure, technical complication, and infection in the short term, while CLAD drives long term mortality (2). In singular organ lung transplantation, it has been suggested that airway hypoxia may increase risk for bronchiolitis obliterans syndrome, a subtype of CLAD, through a multifactorial pathway of hypoxia, inflammation and ischemia leading to fibrosis (21,22). However, these changes seem to be mitigated by post-transplant hypoxia and ischemia-reperfusion injury rather than donor hypoxemia at transplant (23,24). When examining pre-transplant hypoxia, P/F ≤300 mmHg has not been shown to increase PGD, post-transplant pulmonary function, and recipient survival (16). Our results show that the findings by Whitford et al. are also evident in those who receive HLT.
While P/F ratio was not independently associated with survival changes it is important to note that there is a non-significant trend towards decreased long-term survival in these patients, particularly in Era 2. The updated allocation score, allowing for access to more critically ill patients from a more geographically diverse area, may exacerbate the effects of donor hypoxemia in these patients (6). Additionally, changes in center policies and practices regarding coronavirus disease 2019 (COVID-19) may play a role in these differences, particularly for patients reaching 3 years post-transplant during the height of COVID-19 (25). Additionally, long-term data regarding adverse outcomes, such as CLAD, had high rates of missing data and were unable to be analyzed.
Abnormal donor chest X-ray was the only donor or recipient factor independently associated with an increase in survival. Moreover, abnormal donor chest X-ray and abnormal donor bronchoscopy were significantly more common in the hypoxemic donor group. Both these diagnostic measures reflect some underlying level of pre-transplant disease, but this did not result in survival differences between the groups. While abnormal donor chest X-ray was associated with increased survival, this counterintuitive protective effect could be a result of uneven distribution amongst groups, along with potential multicollinearity concerns. Abnormal chest X-ray should not be utilized as sole exclusion criteria as other studies have not found abnormal chest X-rays to impact survival or post-transplant outcomes, especially for mild to moderate consolidations, but should be considered a part of a multifactorial approach to donor selection (26,27).
We report that hypoxemic donor organs for HLT continue to be under-utilized in the years following 2017, despite comparable short and long-term outcomes to donors with P/F ratios >300 mmHg. As HLT increases in occurrence, access to organs remains an important consideration, and usage of organs from hypoxemic donors does not confer adverse outcomes in these patients. However, the small number of patients included warrants caution and a need for further studies regarding extended criteria donors in combined HLT.
Conclusions
In conclusion, this national analysis demonstrates that organs from hypoxemic donor organs are not associated with a survival disadvantage. Furthermore, they represent a significantly underutilized resource. The usage of these organs does merit caution, as these procedures are rare and would benefit from further investigation.
Acknowledgments
We kindly thank the Pauley Heart Center for excellent research and statistical support.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://ccts.amegroups.com/article/view/10.21037/ccts-2025-1-69/rc
Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-2025-1-69/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-2025-1-69/coif). The authors have no conflicts of interest to declare.
Ethical Statement:
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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Cite this article as: Keller M, Kwon YIC, Pei J, Ambrosio M, Al-Yafi M, Patel V, Shah RD, Kasirajan V, Hashmi ZA. Outcomes and utilization of organs from hypoxemic donors in heart-lung transplantation: an observational study. Curr Chall Thorac Surg 2026;8:13.
