Bilateral Lung Transplantation for End-Stage Respiratory Failure from COVID-19 Pneumonia

INTRODUCTION: The SARS-CoV-2 virus is causing severe end-stage fibrosis and respiratory failure in otherwise healthy individuals. Lung transplant (LTX) has been performed internationally in select patients for this indication, but there is limited evidence on its role in COVID-19. We describe a patient who received a bilateral LTX 12 weeks after an initial diagnosis of COVID-19 pneumonia. CASE REPORT: A 51-year-old male with hypertension and presented to an outlying hospital with dyspnea, fever and exposure to SARS-CoV-2. He was hypoxic and a diagnosis of COVID-19 pneumonia was made by nasopharyngeal swab. He was treated with dexamethasone, remdesivir, and convalescent plasma, mechanical ventilation and eventually femoral VV-ECMO cannulation to maintain oxygenation. He was extubated and was transitioned to a left subclavian dual-limb 30 Fr VV-ECMO cannula for improved rehabilitation. He was then transferred to our center for LTX consideration given refractory ARDS. Evaluation for LTX revealed pulmonary hypertension, negative SARS-CoV-2 PCR and deconditioning but no absolute contraindications. He participated in intensive rehabilitation and progressed to assisted steps despite severe deconditioning and hypoxia. He was listed for a bilateral lung transplant with a lung allocation score of 90 and received a donor offer 7 days after listing and after 82 days on ECMO. He underwent bilateral LTX via clamshell exposure with central VA ECMO support. Intraoperatively, the lungs were densely consolidated with severe hilar adenopathy without peripheral adhesions. Post-operatively, he was transitioned back to his original VV ECMO circuit and then decannulated on post-op day 3. Standard induction with basiliximab and immunosuppression with IV methylprednisolone, mycophenolate and tacrolimus was administered. He had a transient elevation of liver enzymes on post-operative day 1 and an early planned tracheostomy was performed due to deconditioning. He has since, been progressing well on oxygen via tracheostomy collar and is able to speak with a one-way valve and participate in rehabilitation. SUMMARY: For patients with irreversible end-stage lung disease after COVID-19 pneumonia, LTX is a viable option. Timely transfer to a lung transplant center and intensive rehabilitation are essential. Standard established immunosuppression and post-transplant protocols should be followed.