*Purpose: Outcomes following lung transplantation (LTx) have been poor compared to those of heart, liver, and kidney transplants, with 5-year survival rates around 50%. To our knowledge, there has been no analysis on factors associated with extended survival past 20 years post-transplantation.

*Methods: All LTx cases performed between 1987 and 2000 within the United Network for Organ Sharing (UNOS) database were reviewed. Adult patients undergoing single or bilateral LTx who survived at least 1-year post-transplant were included. Demographic factors were compared between 1-20 year survivors and those surviving greater than 20 years using Student’s t-test (continuous) and Chi-square test (categorical). Kaplan-Meier and logistic regression analyses were performed to identify trends and risk factors associated with survival long-term survival. Cox regression analysis was then used to assess the impact of protective and risk factors on survival.

*Results: A total of 4,731 recipients were included in the analysis, including 311 recipient who lived greater than 20 years following transplantation. Factors associated with 20-year survival include recipient age 25-35 (OR 0.48-0.51), donor cause of death by head trauma (OR 0.70), female to female donor-recipient gender match (OR 0.74), diagnosis of COPD or Emphysema (OR 1.57), single lung transplant (OR 2.20), and recipient age 55-65 (OR 3.22). Cox regression risk factor analysis showed that patients with 1 or more protective factors were more likely (HR 0.88) to live to 20 years than patients with 1 or more risk factors (HR 1.30).

*Conclusions: The factors that lead to 20-year survival following LTx are different than those classically associated with shorter-term survival. Understanding the longer-term outcomes following LTx is important for all aspects of lung transplantation management, from pre- and post-operative management to donor allocation.

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