Lung transplantation as therapeutic option in acute respiratory distress syndrome for coronavirus disease 2019-related pulmonary fibrosis

Abstract

Background: Critical patients with the coronavirus disease 2019 (COVID-19), even those whose nucleic acid test results had turned negative and those receiving maximal medical support, have been noted to progress to irreversible fatal respiratory failure. Lung transplantation (LT) as the sole therapy for end-stage pulmonary fibrosis related to acute respiratory distress syndrome has been considered as the ultimate rescue therapy for these patients.

Methods: From February 10 to March 10, 2020, three male patients were urgently assessed and listed for transplantation. After conducting a full ethical review and after obtaining assent from the family of the patients, we performed three LT procedures for COVID-19 patients with illness durations of more than one month and extremely high sequential organ failure assessment scores.

Results: Two of the three recipients survived post-LT and started participating in a rehabilitation program. Pearls of the LT team collaboration and perioperative logistics were summarized and continually improved. The pathological results of the explanted lungs were concordant with the critical clinical manifestation, and provided insight towards better understanding of the disease. Government health affair systems, virology detection tools, and modern communication technology all play key roles towards the survival of the patients and their rehabilitation.

Conclusions: LT can be performed in end-stage patients with respiratory failure due to COVID-19-related pulmonary fibrosis. If confirmed positive-turned-negative virology status without organ dysfunction that could contraindicate LT, LT provided the final option for these patients to avoid certain death, with proper protection of transplant surgeons and medical staffs. By ensuring instant seamless care for both patients and medical teams, the goal of reducing the mortality rate and salvaging the lives of patients with COVID-19 can be attained.

Figure 1

The chest image obtained before LT shows extensive pulmonary consolidation with effusions. Patient 1: (A) radiographic image on pre-LT day 1 and (B) chest CT image on pre-LT day 5. Patient 2: (C) radiographic image on pre-LT day 1 and (D) chest CT image on pre-LT day 5. Patient 3: (E) radiographic image on pre-LT day 2, (F) chest CT image on pre-LT day 1. CT: Computed tomography; LT: Lung transplantation.

Figure 2

Transplantation logistics and post-LT rehabilitation. (A) The standardized negative-pressure operating room with the medical team fully equipped and remote monitoring for patient 1. (B) Intercity transportation of patient 2 by a protected medical team. (C) Improved operation setup and team collaboration for patient 3. (D) Intra-operative image obtained when the right lung was transplanted and the left lung was about to be explanted in patient 3. (E) Illustration of explanted lungs from patient 3. (F) Early initiation of the rehabilitation program for patient 2, with psychological support from family and friends (blessing cards on the wall). LT: Lung transplantation.

Figure 3

Post-LT images demonstrated fully expanded lung grafts. (A) Radiographic imaging on post-LT day 20 of patient 2. (B) Radiographic image on post-LT day 11 of patient 3. LT: Lung transplantation; POD: Post-operative day.