US Doctors Perform 1st COVID-19 Double Lung Transplant. Will it Become a Potential Treatment for Severe Cases?

The patient, a woman in her 20s, is currently in stable condition and "improving every day."

A woman in her 20s is currently recovering from a double lung transplant, needed after COVID-19 severely damaged her lungs. The woman, who has not been publicly identified, was treated by surgeons at Northwestern Memorial Hospital in Chicago, and received the transplant on June 5. This is thought to be the first case of a patient receiving a double lung transplant due to the effects of COVID-19.

Ankit Bharat, MD, chief of thoracic surgery and surgical director at the Northwestern Medicine Lung Transplant Program, said during a press conference Thursday that the woman is in "stable condition" and is "improving every day." Dr. Bharat made it clear that the woman was seriously ill when she received the transplant, which replaced her lungs with donor lungs. "If she didn't get the transplant, she would not be alive," he said.

There are a lot of questions surrounding this groundbreaking procedure, including whether this may be a future treatment for other patients with severe forms of COVID-19. Here's what you need to know.

How did doctors decide a double lung transplant due to COVID-19 was necessary?

Dr. Bharat stressed that the woman was really sick—for two months, she had been in the hospital's intensive care unit, sedated on a ventilator and extracorporeal membrane oxygenation (ECMO) machine. Her health was rapidly declining. "She was starting to develop multi-organ failure from the result of the permanent damage that she had," he said. "As a result of the severe injury, the pressure inside the lungs started to really go up and the heart then started to fail. And when the heart starts to fail then the blood starts to back up, so the liver starts to fail and then the kidneys start to fail."

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Northwestern University

In order for doctors to consider her for the double lung transplant, the woman needed to test negative for COVID-19 ahead of the surgery. Once that happened, she was put on a transplant list and doctors obtained consent from the woman's family for the surgery.

Under normal circumstances, patients themselves are given the option to consent to (or at least have knowledge of) a lung transplant in advance, but Dr. Bharat said it was too risky in this woman's case. "Normally we try to wake every patient up before we offer them [a] lung transplant. We want to make sure that the patient knows," he said. "In her situation, we tried to do the same thing, but her lungs were so badly injured, we just could not wake her up. We had to rely on her family, her power of attorney, her mom, and her caregivers to understand her wishes and that's what helped us make the decision."

How does someone typically qualify for a double lung transplant?

The concept of a double lung transplant sounds mind-blowing, but it happens more often than you'd think. Doctors across the country regularly perform this procedure in severely ill patients. Hassan Nemeh, MD, surgical director of thoracic organ transplant at Henry Ford Hospital in Detroit, is one of them. He made headlines in November after performing a double lung transplant on a 17-year-old who was suffering from a vaping-related illness.

Lung transplants are considered a "last resort treatment" in people who are sick with breathing issues, Dr. Nemeh tells Health. "If there is any other treatment other than lung transplantation, we usually do that first," he says. "But if the patient is going to die for sure or they have a 50% chance of survival over the next year or two, this is when we want to do a lung transplant." Dr. Nemeh stresses that lung transplantation is "not a cure" and, while it can improve a patient's health "it has its own issues."

While doctors had to act quickly in the case of the woman's post-COVID-19 transplant, Dr. Nemeh says most people who receive a double lung transplant have a little more time. Double lung transplant candidates are usually evaluated by a series of doctors, Dr. Nemeh says, after which, they're put on a transplant list. The list is run by United Network for Organ Sharing (UNOS), a non-profit organization that oversees all transplant programs in the country. UNOS heads up a national computer system that uses strict standards to make sure that there is ethical and fair distribution of organs. "The sicker someone is, the better their positioning for a transplant," Dr. Nemeh says.

Then, when a compatible donor becomes available, UNOS will call a patient's doctor and ask if they are interested in the lungs. From there, the doctor will evaluate the donor patient's information and, if it seems to be a good fit, will reach out to the patient to see if they are interested. "I've never had anybody say no," Dr. Nemeh says.

What happens during a double lung transplant surgery?

In the case of the first COVID-19 double lung transplant, after the woman was put on the transplant list, she received a new set of lungs two days later, during a 10-hour surgery.

Normally, once there is a donor match and the patient gives the green light, they're prepped for surgery while a team from the hospital center travels to assess and retrieve the donor lung. Not all donor lungs are OK to use—the American Lung Association says that just 28% meet the criteria to be used for a transplant (although Dr. Nemeh says the lungs are usually in good shape once they're matched with a recipient).

"If we get the green light from our team, we then put the transplant recipient in the operating room and start the operation—opening the patient and getting ready for the new lungs," Dr. Nemeh says. "We don't burn any bridges until the new lungs are in the room, safe and sound. Then, we start the actual transplant."

The surgery can be done one of two ways, Dr. Nemeh says: Sequentially, where one lung is replaced, and then the other; or at the same time, in which the patient is put on a heart-lung machine that does the work of the heart and lungs while the heart and lungs are stopped for the surgery.

In a sequential lung transplant, the patient will rely on the use of one lung during the surgery. "Then, we put in a new lung, switch to that, and then replace the other lung," Dr. Nemeh says. But that's not as common as replacing [both] lungs at once. "A lot of our transplant patients' lungs are so far gone, there's no way they can survive on one lung for even an hour," Dr. Nemeh says. That means most patients are put on a heart-lung machine during surgery. "That gives you the time to deflate the lungs and put them in," Dr. Nemeh says. "During the course of surgery, you have several hours to do this."

During the surgery, the main blood vessels and airway of the new lung are sewn to the patient's own blood vessels and airway, according to the US National Library of Medicine's Medline Plus resource. The donor or lung is stitched into place, and chest tubes are inserted to drain air, fluid, and blood out of the chest for several days to allow the lungs to fully re-expand.

What is recovery like following a double lung transplant?

While the woman who received the COVID-19 lung transplant is currently stable and doing well, she may have quite a long road ahead of her. "Recovery is really quite substantial," pulmonary critical care expert Reynold Panettieri, MD, director of the Institute for Translational Medicine and Science at Rutgers University, tells Health. Double lung transplant patients can expect to be in the hospital anywhere from a week to 21 days after surgery, Medline Plus says. "It depends on how sick they were," Dr. Nemeh says. "The sicker the patient is coming in, the sicker they are afterward."

After surgery, the overall recovery time is about six months, and patients usually need to have regular checkups. They are also put on anti-rejection medication, so their body's immune system doesn't attack the new lungs. They'll need to stay on the medication for the rest of their life, Dr. Nemeh says.

Dr. Panettieri points out that lung transplants aren't perfect, though. "The five-year survival rate of a patient who undergoes a lung transplant is worse than those who have lung cancer—it's less than 50%," he says. "However, there are no other options."

While there are risks involved with double lung transplants, including blood clots, damage to organs from anti-rejection medication, and a future risk of certain cancers, Dr. Panettieri has seen success with double lung transplants. "I have had patients who have gone back to competitive athletics and could actually start to run," he says. "It is a game changer. When all goes well, it's absolutely fabulous."

So, could a double lung transplant be a potential treatment for patients with severe COVID-19?

More research is needed, according to Dr. Bharat. "We want other transplant centers to know that while the transplant procedure in these patients is quite technically challenging, it can be done safely, and it offers the terminally ill COVID-19 patients another option for survival," he said during the press conference.

But while this is a possible treatment option for people who have severe forms of COVID-19, it's unlikely this will happen often, Amesh A. Adalja, M.D., senior scholar at the Johns Hopkins Center for Health Security, tells Health. "To get a lung transplant, you have to be young and otherwise healthy," he says. "The majority of patients with severe cases of COVID-19 are elderly and wouldn't be eligible for a lung transplant anyway because of their age and comorbidities." Dr. Nemeh, too, says he doesn't anticipate a big need in lung transplants from COVID-19 patients. "All of this is a temporary treatment until a vaccine becomes available," he says.

As for the woman who received the transplant, doctors maintain that she is recovering nicely, and has even regained some of her ability to speak. "Yesterday she smiled and told me this one sentence: She said, 'Doc, thank you for not giving up on me,'" Dr. Bharat said. "She's able to FaceTime with her family. She's able to talk to her significant others."

The information in this story is accurate as of press time. However, as the situation surrounding COVID-19 continues to evolve, it's possible that some data have changed since publication. While Health is trying to keep our stories as up-to-date as possible, we also encourage readers to stay informed on news and recommendations for their own communities by using the CDC, WHO, and their local public health department as resources.

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