Double lung transplants slated here

Weapon in war on COVID

With a small but growing number of people whose lungs have been decimated by COVID-19 in need of double lung transplants, doctors at University Hospital are on the cusp of performing the complex surgery.

To date, a handful of transplant centers in the U.S. — including one in Houston— has transplanted lungs into patients who largely were healthy before the virus caused irreversible damage. The surgeries have been considered only for patients who have no other chance of survival.

“We feel comfortable that we’re ready to transplant a COVID patient,” said Dr. Edward Sako, surgical director of the lung transplant program at University Transplant Center and a professor of cardiothoracic surgery at UT Health San Antonio. “We’re poised to do it.”

In the most severe cases, the coronavirus causes acute respiratory failure, leading to a buildup of fluid in the lungs. The organs’ delicate air sacs also can suffer damage from mechanical ventilators, which often are required to support the breathing of critically ill COVID patients.

Transplant surgeons who have operated on coronavirus patients have reported complicated procedures, where they have excised inflamed lung tissue that had become fused to chest cavities.

Typically, a lung transplant will take five to six hours, Sako said. The surgery for the first COVID-19 double lung transplant pa

tient in the U.S. took about 10 hours.

“In many of these patients, the level of scarring within the chest is much more advanced,” Sako said, adding, “It’s nothing terribly new. It’s just maybe a combination of some of the most difficult parts of many of our transplants, rolled into one.”

Some of the COVID-19 patients who have received transplants were acutely ill and had to rely on ventilators and extracorporeal membrane oxygenation, or ECMO, machines, which directly oxygenate the blood.

But there’s another group of COVID-19 patients who also could require transplants in the coming months — those who have recovered enough to leave the hospital but still suffer from long-term lung problems.

“We’re just starting to get this trickle — which I think is going to become much more than a trickle — of these patients who have postCOVID chronic disease,” said Dr. Deborah Levine, medical director of University’s lung transplant program and director of the hospital’s Pulmonary Hypertension Center.

With both types of patients, Levine said transplant centers must walk a fine line when evaluating and selecting individuals for the procedure.

Candidates have to be sick enough to need a transplant, but strong enough to withstand such an invasive surgery, which carries higher risks than other types of transplants.

So far, only a small number of people have qualified. The sickest COVID-19 patients tend to have underlying health conditions that would disqualify them for a transplant, and the disease can damage multiple organ systems, further limiting the pool of patients ultimately listed for neworgans.

“The patients really need to be strong. They need to be not frail. They need to be conditioned. They need to be able to do physical rehab, even if it’s on the ventilator or on ECMO,” Levine said.

As the pandemic has progressed, growing numbers of transplant centers across the country have been evaluating COVID-19 patients for new organs.

The country’s first lung transplant for a COVID-19 patient occurred in June at Northwestern Memorial Hospital in Chicago, for a woman in her late 20s who spent weeks on a ventilator and an ECMO machine.

Soon after, University of Florida Health Shands Hospital began performing transplant surgeries for COVID-19 patients.

In late August, the first COVID-19 lung transplant in Texas was performed at Memorial Hermann in the Texas Medical Center for a Houston-area man in his late 60s who avoided intubation but permanently needed supplemental oxygen after his bout with the virus.

And earlier this month, Vanderbilt University Medical Center announced it had performed a heart-lung transplant in late September for a young man who had heart disease before he fell ill with COVID-19.

Other centers also may have performed COVID-19 transplants but not publicized them, Levine said, since outcomes for the patients still are unclear.

Sako said many centers, University included, are taking a measured, deliberate approach to these transplants.

“We still have all these other patients, with limited resources, that we need to treat as best we can,” he said.

This summer, tens of thousands of people in the San Antonio area contracted the coronavirus during a severe wave of infections that pushed local hospitals near capacity.

During the peak of the crisis in mid-july, more than 1,200 people were hospitalized, and hundreds of critically ill patients were inundated in intensive care units.

Some of those patients potentially could qualify for transplants.

Several COVID-19 patients from San Antonio already have undergone double lung transplants, but their surgeries were not handled locally.

In 2019, there were more than 2,700 lung transplants across the country, accounting for less than 7 percent of all transplants.

Compared to other types of transplants, people who receive new sets of lungs tend to have higher rates of acute and chronic rejection. Four to five years after their surgeries, Levine said, about half of the patients experience chronic lung allograft dysfunction, where their lungs are not functioning properly.

It’s against that backdrop — with limited data and no way of knowing long-term outcomes — that lung transplant surgeons now are wading into surgeries for COVID-19 patients. National guidelines for the surgeries also have been a “moving target,” Levine said, evolving over the course of the year.

Unlike most other types of lung transplants, which usually are needed after extended illnesses from diseases like cystic fibrosis or chronic obstructive pulmonary disease, COVID-19 patients are in sudden need of a transplant after a shorter severe illness.

“This one is, ‘Oh my gosh, this patient got sick, he has bad lungs, and now he needs a lung transplant,’” she said. “All the way around, it’s something so different and so remarkable for everybody.”