BACKGROUND: Single lung transplantation (SLT) has been shown to be associated with worse long-term outcomes than bilateral lung transplantation (BLT), but often is performed in older adults at risk of not tolerating BLT. RESEARCH QUESTION: How do the outcomes of SLT and BLT compare among older adult recipients? STUDY DESIGN AND METHODS: The Scientific Registry of Transplant Recipients database (2005-2022) was queried for lung transplant recipients aged 65 years older. Patients were stratified by whether they underwent BLT or SLT and were propensity matched. Baseline characteristics and morbidity were compared with frequentist statistics. Survival was analyzed via Kaplan-Meier estimation. Risk factors for mortality were identified with Cox regression. RESULTS: Of 9,904 included patients, 4,829 patients (48.8%) underwent SLT. Patients who underwent SLT had lower lung allocation scores (39.6 vs 40.6
P <
.002), more interstitial lung disease (74.4% vs 64.6%
P <
.002), and lower rates of bridging (0.7% vs 2.4%
P <
.002). Groups did not differ significantly by sex, BMI, or donor characteristics. Propensity matching resulted in 2,539 patients in each group. On matched analysis, patients undergoing SLT had shorter lengths of stay (14 days vs 18 day), lower reintubation rates (14.7% vs 19.8%), and less postoperative dialysis use (4.2% vs 6.4%
P <
.002 for all). Patients who underwent SLT had comparable survival at 30 days (97.6% vs 97.3%
P = .414) and 1 year (85.5% vs 86.3%
P = .496), but lower survival at 5 years (45.4% vs 53.4%
P <
.002) on matched analysis. SLT was a risk factor for 5-year mortality (adjusted hazard ratio, 1.19
P <
.002). INTERPRETATION: Our findings show that in older adults, SLT is associated with less morbidity and comparable early survival relative to BLT, but lower 5-year survival. This suggests that SLT is reasonable to perform in older adults at high risk of not tolerating BLT.