Early outcomes after lung transplantation for severe COVID-19: a series of the first consecutive cases from four countries

Abstract

Background Lung transplantation is a life-saving treatment for patients with end-stage lung disease; however, it is infrequently considered for patients with acute respiratory distress syndrome (ARDS) attributable to infectious causes. We aimed to describe the course of disease and early post-transplantation outcomes in critically ill patients with COVID-19 who failed to show lung recovery despite optimal medical management and were deemed to be at imminent risk of dying due to pulmonary complications. Methods We established a multi-institutional case series that included the first consecutive transplants for severe COVID-19-associated ARDS known to us in the USA, Italy, Austria, and India. De-identified data from participating centres—including information relating to patient demographics and pre-COVID-19 characteristics, pretransplantation disease course, perioperative challenges, pathology of explanted lungs, and post-transplantation outcomes—were collected by Northwestern University (Chicago, IL, USA) and analysed. Findings Between May 1 and Sept 30, 2020, 12 patients with COVID-19-associated ARDS underwent bilateral lung transplantation at six high-volume transplant centres in the USA (eight recipients at three centres), Italy (two recipients at one centre), Austria (one recipient), and India (one recipient). The median age of recipients was 48 years (IQR 41–51); three of the 12 patients were female. Chest imaging before transplantation showed severe lung damage that did not improve despite prolonged mechanical ventilation and extracorporeal membrane oxygenation. The lung transplant procedure was technically challenging, with severe pleural adhesions, hilar lymphadenopathy, and increased intraoperative transfusion requirements. Pathology of the explanted lungs showed extensive, ongoing acute lung injury with features of lung fibrosis. There was no recurrence of SARS-CoV-2 in the allografts. All patients with COVID-19 could be weaned off extracorporeal support and showed short-term survival similar to that of transplant recipients without COVID-19. Interpretation The findings from our report show that lung transplantation is the only option for survival in some patients with severe, unresolving COVID-19-associated ARDS, and that the procedure can be done successfully, with good early post-transplantation outcomes, in carefully selected patients. Funding National Institutes of Health. Video Abstract Early outcomes after lung transplantation for severe COVID-19

Covid-19 in recipients of heart and lung transplantation: Learning from experience

“…The SARS-CoV-2 pandemic has similarly impacted the process of lung transplantation globally, with dramatic reductions in transplant volume, 15 the ever-present risk of donor-to-recipient transmission, 16 the advent of lung transplantation for severe COVID-19, 17 and the potential for significant morbidity and mortality in patients with end-stage lung disease acquiring infection before 18 or after 4 transplantation. In this issue, Mohanka and colleagues describe their experience in 25 lung transplant recipients from Dallas, Texas infected with SARS-CoV-2.…”

Pulmonary Involvement in COVID-19 and ‘Long Covid’: The Morbidity, Complications and Sequelae

“…Tocilizumab, the monoclonal antibody against IL-6, has been claimed to have a bene icial effect on post-COVID-19 patients with severe lung damage and elevated interleukin six levels. As the inal option, lung transplantation has been considered and tried [52,53].…”

Lung transplantation for COVID-19-associated ARDS

“…Good potential for recovery, thorough evaluation before transplantation, single organ failure, and informed consent are required to ensure high success rates. In Bharat and colleagues' case series, 1 patients did not necessarily meet these requirements. As expected, the patients had a complicated intraoperative and postoperative course (eg, mass transfusion, continued extracorporeal support, re-thoracotomy, primary graft dysfunction, and prolonged postoperative stay in the intensive care unit [ICU]).…”

“…We read with interest the study in The Lancet Respiratory Medicine by Ankit Bharat and colleagues, 1 regarding a case series of patients with COVID-19-associated acute respiratory distress syndrome (ARDS) who were bridged to lung transplantation by extracorporeal membrane oxygenation (ECMO). COVID-19 has affected millions of patients, some of whom will develop ARDS 2 and some of whom will die.…”

“…Around 600 patients are listed for lung transplantation in the Eurotransplant region. At most, 1% of these patients has a lung allocation score (LAS) of 85 and above, thus the reported patients 1 will outperform 99% of patients on the current waiting list. At our centre alone, we identified five patients who fulfilled the criteria mentioned by the authors.…”