Lung transplantation as therapeutic option in acute respiratory distress syndrome for COVID-19-related pulmonary fibrosis

Chen, Jing-Yu et al. Lung transplantation as therapeutic option in acute respiratory distress syndrome for coronavirus disease 2019-related pulmonary fibrosis, Chinese Medical Journal: June 20, 2020 - Volume 133 - Issue 12 - p 1390-1396 doi: 10.1097/CM9.0000000000000839

Review written by:

Danya Ziazadeh, edited by Robert Parry

Yellow - The case series demonstrates that lung transplantation (LT) can be successfully performed in patients with end-stage respiratory failure caused by COVID-19 related pulmonary fibrosis, but the small sample size (n=3) limits the study’s validity and impact.

It has been established that patients in critical condition with COVID-19 often progress to irreversible fatal respiratory failure, even with the provision of invasive mechanical ventilation (MV) and extracorporeal membrane oxygenation (ECMO). The authors present a case series, which occurred between February 10 and March 10, 2020, of 3 male patients in China. Each patient received LT as a therapy for end-stage pulmonary fibrosis from COVID-19.


Lung recipients were 58-73 years old, and all presented with the following comorbidities: Patient 1 with hypertension; Patient 2 with HBV infection; and Patient 3 with diabetes mellitus, chronic kidney disease, coronary heart disease, atrial fibrillation, and COPD. Prior to LT, chest imaging confirmed pulmonary consolidation with fibrotic change, convalescent plasma infusion was performed, and antiviral drugs and supportive care were provided to all patients. In addition, all three patients demonstrated high SOFA scores (mean = 16), and high D-dimer values (all > 12 𝛍g/mL). COVID-19 associated coagulopathy was found to be a common complication of patients with severe infection, as two of the three patients suffered uncontrolled intra-pulmonary bleeding.


Urgent assessment for LT was performed while each patient received MV and ECMO, and nucleic acid testing from different bodily sites was repeated. Results confirmed negative COVID-19 status, though Patient 2 demonstrated mild positive results in fecal samples. During transplantation, all patients remained on MV and ECMO. In each of the three cases, the right lung was explanted first. Consolidation, pulmonary edema, and congestion with intrapulmonary bleeding were observed. All patients had successful right LTs. Patient-specific outcomes include:

  • Patient 1: 1) During left LT, ventricular fibrillation developed, resulting in cardiac arrest. 2) An emergent heart transplant was performed. 3) Although the heart briefly returned to normal rhythm, bleeding could not be controlled and the transplanted heart arrested, resulting in the patient’s death.

  • Patient 2: 1) A narrow space in the left chest cavity was observed, and a lobar lung transplant using the left upper lobe was performed. 2) The patient survived, and consciousness was regained on post operative day (POD) 1. 3) No abnormalities in follow-up bronchoscopies were found, chest tubes were removed on POD 5, and post-op nucleic acid tests were found to be negative.

  • Patient 3: 1) During the left lung explantation, the patient developed recurrent atrial fibrillation, leading to hemodynamic instability. 2) With intensive medical management, the left LT was successfully performed and the patient survived. 3) Consciousness was regained on POD 1. 4) No abnormalities in follow-up bronchoscopies were found, chest tubes were removed on POD 5, and post-op nucleic acid tests were found to be negative.

The authors note that three points must be confirmed before LT is warranted: 1) confirmed irreversible respiratory failure, despite the provision of medical support; 2) confirmed positive-turned-negative virology status due to continuous nucleic acid testing with samples from multiple bodily sites; and 3) confirmed absence of other organ system dysfunction. The authors conclude that with comprehensive preparation of both the patients and surgeons, successful LT can reduce the high mortality rate associated with end-stage COVID-19 patients.

Review Notes
 
  • As the article presented is a case series, it is merely descriptive in nature.

  • The availability of suitable lungs for transplant limits the amount of LT that can be performed.

  • The study had a small sample size, as only 3 patients’ courses were described.

  • At the time of writing, the post-operative follow-up is less than 30 days.

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