Bilateral pneumonectomy and lung transplant for COVID-19–induced respiratory failure (2022)

Central MessageBilateral pneumonectomy with a novel cannulation strategy followed by lung transplantation can be a rescue measure for those patients with severe, irreversible lung damage caused by SARS-CoV-2.See Commentary on page 288. Bilateral pneumonectomy with a novel cannulation strategy followed by lung transplantation can be a rescue measure for those patients with severe, irreversible lung damage caused by SARS-CoV-2. See Commentary on page 288. There are few published descriptions of lung transplant for COVID-19 (Table E1). Here, we describe a COVID-19 polymerase chain reaction (PCR) test-positive patient who underwent bilateral pneumonectomy before lung transplant using a novel cannulation strategy. Institutional review board approval was not required for this case study and the patient provided consent. A 37 year-old woman was admitted with COVID-19 infection required intubation on day 6, and venovenous (VV) extracorporeal membrane oxygenation (ECMO) on day 8. She was treated for Stenotrophomonas superinfection. On day 20, she was enrolled in a trial for application of stem cells via the ECMO circuit, which occurred without complication. For the next several weeks, she required full ECMO with an inability to wean. On day 37, due to persistent positivity (based on PCR test), a cycle threshold (Ct) was obtained and resulted at 30, indicating she may still have a high viral load,1Prasad A. Ghodsizad A. Brehm C. Kozak M. Koerner M. El Banayosy A. et al.Refractory pulmonary edema and upper body hypoxemia during veno-arterial extracorporeal membrane oxygenation—a case for atrial septostomy.Artif Organs. 2018; 41: 664-669Crossref Scopus (17) Google Scholar which could complicate transplantation. We elected to perform pneumonectomy before transplant to reduce or eliminate the viral reservoir. She was listed for transplant on day 39, and 3 days later underwent bilateral pneumonectomy at which time her VV ECMO was converted to central venoarterial ECMO using a novel cannulation strategy taking advantage of the patient's known patent foramen ovale (PFO). Venous drainage occurred with 3 cannulas: 1 via the right internal jugular vein and 1 from the left femoral vein. The third cannula was placed in the right pulmonary artery (PA). All blood was returned to a single ECMO device using Y-connectors. The blood was then returned to the patient via an arterial cannula into the ascending aorta. Filling of the left heart occurred primarily from the Thebesian veins (Figure 1). Postoperative echocardiogram demonstrated a decompressed right and left ventricle. There was no evidence of mitral regurgitation and even with the left to right shunt induced by ECMO and the PFO, the left ventricle did fill and was able to expel blood into the aorta with inotropic support. Her chest was closed on postoperative day 2. On day 48, donor lungs were found. The left lung was not appropriate for transplantation but fortunately the right lung was oversized. Based on the length of time she had been on ECMO and now 5 days after bilateral pneumonectomy, the multidisciplinary team believed it was prudent to proceed with single lung transplant. She was converted to VV ECMO and her PA cannula was removed. She tolerated routine postoperative immunosuppression and no additional antiviral therapy was added. Her posttransplant PCR test result converted to negative and remained so (Table 1). She was decannulated from ECMO approximately 8 weeks after transplant. Six months posttransplant, she was alert and oriented, off mechanical ventilation, and debilitated but participating in rehabilitation.Table 1Reverse transcription polymerase chain reaction (PCR) results over timeHospital dayPCR test resultEventDay 21PositiveDay 34PositiveDay 39Bilateral pneumonectomyDay 42Positive∗The patient turned negative immediately following her single lung transplant. We do not believe this is a result of receiving her single lung transplant, but rather the result of her bilateral pneumonectomy 5 days prior. She did have 1 PCR performed after pneumonectomy that was positive, but we do not have cycle threshold data on this specimen and cannot determine its significance.Day 45Single lung transplantDay 46NegativeDay 49NegativeDay 51NegativeDay 54NegativeDay 56NegativeDay 59NegativeDay 61NegativeDay 62Negative∗ The patient turned negative immediately following her single lung transplant. We do not believe this is a result of receiving her single lung transplant, but rather the result of her bilateral pneumonectomy 5 days prior. She did have 1 PCR performed after pneumonectomy that was positive, but we do not have cycle threshold data on this specimen and cannot determine its significance. Open table in a new tab Substituting the lungs with mechanical support requires a thoughtful strategy that prevents stasis and distention of the heart. Ligation of the PA removes the right heart outlet, and ligation of the pulmonary veins compromises left heart preload. We maintained flow across the right heart by inserting a cannula into the right PA to allow for right ventricle ejection and reduce afterload. For the left heart, we relied on the Thebesian veins for preload. After months of critical illness and refractory hypoxia, our patient's left heart function was reduced with an ejection fraction <40%, leading to concern about the ability of the left ventricle to maintain adequate ejection. Her PFO provided a strategy by which we could unload the left ventricle, and allow for flow in the left atrium by creating a left to right shunt. Two other strategies for ECMO cannulation after bilateral pneumonectomy are described in the literature (Figure 2 and Video 1). Cypel and colleagues2Cypel M. Waddell T. Singer L.G. del Sorbo L. Fan E. Binnie M. et al.Bilateral pneumonectomy to treat uncontrolled sepsis in a patient awaiting lung transplantation.J Thorac Cardiovasc Surg. 2017; 153: e67-e69Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar utilized 2 ECMO circuits to accomplish flow in all 4 chambers, and Barac and colleagues3Barac Y.D. Bryner B. Bonadonna D. Wolfe C. Reynods J. Haney J. et al.Bilateral pneumonectomy with veno-arterial extracorporeal membrane oxygenation as a bridge to lung transplant.J Heart Lung Transplt. 2019; 38: 1231-1232Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar modified native anatomy by anastomosing the left PA to the left pulmonary vein to accomplish the same goal. The advantages of our strategy are 2-fold. First, only 1 ECMO device is utilized reducing the risk of thrombosis and hemolysis. Second, it is technically simpler; that is, no anastomosis. This model could be replicated in patients without a PFO by performing atrial septostomy at the time of the pneumonectomy.1Prasad A. Ghodsizad A. Brehm C. Kozak M. Koerner M. El Banayosy A. et al.Refractory pulmonary edema and upper body hypoxemia during veno-arterial extracorporeal membrane oxygenation—a case for atrial septostomy.Artif Organs. 2018; 41: 664-669Crossref Scopus (17) Google Scholar In our patient, PFO closure at the time of transplant was deferred due to adequate PA pressures. Ct is used to describe viral load with counts <25 indicative of a high viral load, and counts >31 indicative of low viral load.4Rabaan A.A. Tirupathi R. Sule A.A. Aldali J. Mutair A.A. Alhumaid S. et al.Viral dynamics and real time RT-PCR Ct values correlate with disease severity in COVID-19.Diagnostics. 2021; 11: 1091-1109Crossref PubMed Scopus (43) Google Scholar Results between 25 and 30 may indicate active ongoing infection. Her Ct results, coupled with her dismal clinical status, led to the strategy of bilateral pneumonectomy first, as has been described in cystic fibrosis patients.2Cypel M. Waddell T. Singer L.G. del Sorbo L. Fan E. Binnie M. et al.Bilateral pneumonectomy to treat uncontrolled sepsis in a patient awaiting lung transplantation.J Thorac Cardiovasc Surg. 2017; 153: e67-e69Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar,3Barac Y.D. Bryner B. Bonadonna D. Wolfe C. Reynods J. Haney J. et al.Bilateral pneumonectomy with veno-arterial extracorporeal membrane oxygenation as a bridge to lung transplant.J Heart Lung Transplt. 2019; 38: 1231-1232Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Based on our experience, patients with COVID-19 requiring ECMO for 4 to 6 weeks with no signs of recovery should be considered for transplant. Additionally, if they show signs of persistent viral infection, pneumonectomy before transplant may be the preferred strategy. More study is needed to determine which patients would benefit, particularly at a time when resources are of paramount importance. https://www.jtcvstechniques.org/cms/asset/3cc77829-66a9-45ef-835f-b8f9f8fa2df1/mmc1.mp4Loading ... Download .mp4 (17.61 MB) Help with .mp4 files Video 1Brief description of the indications, benefits, and challenges of extracorporeal membrane oxygenation after bilateral pneumonectomy as well as a comparison of 3 described cannulation strategies. Video available at: https://www.jtcvs.org/article/S2666-2507(22)00050-5/fulltext. Download .jpg (.08 MB) Help with files Video 1Brief description of the indications, benefits, and challenges of extracorporeal membrane oxygenation after bilateral pneumonectomy as well as a comparison of 3 described cannulation strategies. Video available at: https://www.jtcvs.org/article/S2666-2507(22)00050-5/fulltext. Table E1Published descriptions of lung transplant for COVID-19AuthorLocationDate of publicationNo. of patientsDays from infection to transplantPreoperative PCR statusTechniqueSurvival (%)Chen and colleaguesE1Chen J.Y. Qiao K. Liu F. Wu B. Xu X. Jiao G.-Q. et al.Lung transplantation as therapeutic option in acute respiratory distress syndrome for coronavirus disease 2019-related pulmonary fibrosis.Chin Med J. 2020; 133: 1390-1396Crossref PubMed Scopus (108) Google ScholarChinaJune 2020342, 37, 44NegativeBilateral lung66Han and colleaguesE2Han W. Zhu M. Chen J. Zhang J. Zhu S. Li T. et al.Lung transplantation for elderly patients with end-stage COVID-19 pneumonia.Ann Surg. 2020; 272: e33-e34Crossref PubMed Scopus (58) Google ScholarChinaAugust 2020230, 28NegativeBilateral lung100Lang and colleaguesE3Lang C. Jaksch P. Hoda M.A. Lang G. Staudinger T. Tschernko E. et al.Lung transplantation for COVID–19-associated acute respiratory distress syndrome in a PCR-positive patient.Lancet Respir Med. 2020; 8: 1057-1060Abstract Full Text Full Text PDF PubMed Scopus (76) Google ScholarVienna, AustriaAugust 2020158PositiveBilateral lung100Bharat and colleaguesE4Bharet A. Querrey M. Markov N.S. Kim S. Kurihara C. Garza-Castillon R. et al.Lung transplantation for patients with severe COVID-19.Sci Transl Med. 2020; 12: eabe4282Crossref PubMed Google ScholarUnited States (Chicago, Ill)December 2020342, 100, 28NegativeBilateral lung100Ghodsizad and colleagues (current study)United States (Miami, Fla)–148PositiveBilateral pneumonectomy/ECMO —> single lung100PCR, Polymerase chain reaction; ECMO, extracorporeal membrane oxygenation. Open table in a new tab PCR, Polymerase chain reaction; ECMO, extracorporeal membrane oxygenation.