Lung Transplantation in COVID-19 Induced End Stage Lung Disease

INTRODUCTION: In a subset of patients COVID-19 induced lung injury progresses to irreversible lung damage and pulmonary fibrosis. Bilateral orthotopic lung transplant (BOLT) has been used as a rescue therapy in these patients. We describe four patients who were bridged to BOLT using venovenous extracorporeal membrane oxygenation (VV-ECMO). CASE REPORT: Between October 13, 2020 and February 14, 2021, four patients with SARS-CoV-2 infection underwent BOLT for end-stage pulmonary fibrosis demonstrated on computed tomography. Median age was 42 years and three were male. One patient had a prior history of undifferentiated interstitial lung disease managed with chronic steroids. Pre-transplant hospital course was complicated by right ventricular failure due to pulmonary hypertension in two patients and ventilator-associated pneumonia in one. One patient developed heparin-induced thrombocytopenia requiring anticoagulation with bivalirudin perioperatively. Three patients were non-ambulatory and bedridden for a median of 54 days prior to surgery. Timing of transplantation ranged from hospital day 26 - 68 with a median of 48 days. At the time of transplant, three patients were mechanically ventilated via tracheostomy, while all were on VV-ECMO a median of 27 (IQR 11 - 42) days. All patients underwent BOLT via clamshell exposure utilizing cardiopulmonary bypass (CPB) with aortic and right atrial cannulation. VV-ECMO was discontinued intraoperatively in all cases after initiating CPB. All patients required intraoperative blood transfusion with a median of 3 units. The three patients with tracheostomy prior to transplant were liberated from the ventilator a median of 9 days postoperatively and decannulated from their tracheostomy a median of 11 days postoperatively. Aside from one patient requiring short courses of hemodialysis, there were no significant postoperative complications. Patients were discharged a median of 17 (14 - 20) days following surgery. After a median follow-up of 226.5 (223 - 257.75) days, all four patients were alive with no supplemental oxygen requirement. SUMMARY: Pulmonary fibrosis secondary to COVID-19 pneumonia can be successfully treated with VV-ECMO and subsequent lung transplantation in select patients. Special consideration should be given to this patient population as they may not meet traditional listing requirements. We report a 100% oxygen-free survival rate at six months.