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.

Figure 1

Imaging and gross pathology of transplant recipients Typical chest radiograph (A) and CT (B) of a recipient undergoing lung transplantation for COVID-19-associated acute respiratory distress syndrome at the time of listing, showing honeycombing, consolidation, and bronchiectasis. (C) A chest radiograph of a representative recipient at the time of hospital discharge is given for comparison. (D–G) Typical radiological and gross pathological features seen in our patients at the time of listing: diffuse fibrosis in all lobes (D), pneumothoraces and shrinking lungs (E), parenchymal necrosis (F), and cavernous changes (G).

Figure 2

Timeline depicting different treatment phases throughout hospitalisation and follow-up ICU=intensive care unit. MV=mechanical ventilation. ECMO=extracorporeal membrane oxygenation. Tx=transplantation.

Figure 3

SHIELD tissue-cleared imaging of human lungs in late-stage severe COVID-19 Cleared lung tissue allowed visualisation of the collagen structure and matrix of the lung tissue (cyan; original magnification 10×). (A) Normal collagen matrix of human lungs. (B) Destroyed matrix with inflammatory cells in explanted lungs from a lung transplant recipient with late-stage severe COVID-19. (C) Explanted lungs from a lung transplant recipient with end-stage emphysema. (D) Explanted lungs from a lung transplant recipient with end-stage α1-antitrypsin deficiency.