Survival high for patients undergoing lung transplant for COVID-19-associated ARDS

In a single-center case series published in JAMA, survival after lung transplant was 100% among 30 patients with COVID-19-associated acute respiratory distress syndrome.

“This study proves lung transplantation is highly effective and successful in critically ill COVID-19 patients,” Ankit Bharat, MD, chief of thoracic surgery at Northwestern Medicine and executive director of the Canning Thoracic Institute, Chicago, said in a related press release. “We were especially surprised to find that patients with COVID-19 did not develop rejection of the lungs after transplant.”

The case series included 102 consecutive patients who underwent lung transplant at Northwestern University Medical Center from January 2020 to September 2021. Thirty patients had COVID-19-associated ARDS (median age, 53 years; 43% women) and 72 had chronic end-stage lung disease without COVID-19 (median age, 62 years; 44% women). The final follow-up was in November 2021.

The primary outcomes were postoperative complications, ICU and hospital length of stay, and survival after lung transplant.

Lung transplant recipients with COVID-19-associated ARDS had higher median lung allocation scores (85.8 vs. 46.7; range 0-100, with higher score indicating severely ill), lower median time on the transplant waitlist (11.5 vs. 15 days) and a higher use of preoperative venovenous extracorporeal membrane oxygenation (56.7% vs. 1.4%) compared with recipients without COVID-19.

Those with COVID-19-associated ARDS received a median transfusion of 6.5 U packed red blood cells compared with 0 U among those without COVID-19 during transplant.

Patients with COVID-19-associated ARDS also had a higher use of intraoperative venoarterial ECMO (96.7% vs. 62.5%) and a higher median operative time (8.5 vs. 7.4 hours) compared with patients without COVID-19.

After lung transplant, patients with COVID-19-associated ARDS had a higher rate of primary graft dysfunction within 72 hours (70% vs. 20.8%), a longer median time of invasive mechanical ventilation (6.5 vs. 2 days), a longer median duration of ICU stay (18 vs. 9 days), a longer median duration of hospitalization after lung transplant (28.5 vs. 16 days) and a higher rate of permanent hemodialysis (13.3% vs. 5.5%) compared with patients without COVID-19.

During the final follow-up, all 30 patients with COVID-19-associated ARDS who underwent lung transplant were alive compared with 83% of patients without COVID-19 who underwent lung transplant.

Antibody-mediated rejection did not occur among lung transplant recipients with COVID-19-associated ARDS; with the rate of antibody-mediated rejection was 12.5% among those without COVID-19.

“As shown in the study, COVID-19 lung transplant procedures are much more difficult and require more resources. These procedures are only going to be successful when done at select transplant centers with high levels of experience and necessary resources,” Scott Budinger, MD, chief of pulmonary and critical care medicine at Northwestern Medicine and medical director of the Canning Thoracic Institute, said in the release. “While these are lifesaving procedures, they carry substantial risk. Patients need to take medications for the rest of their lives and despite that, they will eventually reject their lungs. Transplant centers should be selective in who they consider for COVID-19 lung transplant procedures, and patients should seek a second opinion when declined for transplant because not all centers have the expertise to perform them.”

Northwestern Medicine has performed 40 lung transplants on patients with COVID-19, according to the release.

“We hope lung transplantation will become a standard treatment of care when all other medical therapies fail to achieve lung recovery and get the patients off the ventilator and ECMO,” Bharat said. “We also hope patients aren’t declined access to this lifesaving intervention due to insurance denials.”

Reference:

• Northwestern Medicine reports positive outcomes in COVID-19 patients who underwent lung transplants. Published Feb. 1, 2022. Accessed Feb. 2, 2022.