Hundreds of patients have received lung transplants due to COVID-19 in the United States. According to data from the United Network for Organ Transplants (UNOS), in the U.S., about one in 10 lung transplants now go to COVID-19 patients.
We sat down with Selim M. Arcasoy, MD, Medical Program Director of the Lung Transplant Program at NewYork-Presbyterian/Columbia, to learn more about COVID-19 related transplants—when they happen, how it works, and what this means for patients, surgeons, and the future of transplant surgery in America.
[Note: This conversation was lightly edited for the page]
Can you tell me a bit about how COVID damages the lungs, and what would lead to the point of transplant?
COVID seems to cause very severe pneumonia in some patients, leading to acute respiratory distress syndrome (ARDS) and even leading to pulmonary fibrosis in some patients. Patients who develop ARDS typically end up on high flow oxygen, many need mechanical ventilator support, and many need extracorporeal membrane oxygenator (ECMO) support. And some of those patients could never come off of those supports.
We've been consulted for several people who've been on vent and ECMO for five or six months seeking a lung transplant. And some of those patients recover partially, or never progress to going on a ventilator and ECMO but are stuck with very rapid development of pulmonary fibrosis that results in chronic hypoxemic respiratory failure. They either have to stay in the hospital, requiring a lot of oxygen, or they're eventually discharged home, needing nasal or mask oxygen or even a tracheostomy. Those people would be candidates for transplants.
So, for the subacute cases, say, maybe six or eight weeks after the development of acute COVID-19, and more subacute to chronic cases, they are several months beyond their initial infection. That's the typical patient population.
Has COVID-19 impacted the overall incidence of lung transplant in the US?
About eight months after the pandemic exploded in the US, UNOS actually came up with diagnostic codes for “COVID ARDS” and “COVID pulmonary fibrosis,” as categories that belong to different disease groups and are assigned lung allocation scores. Previously, it would be, say, just “general pulmonary fibrosis” group, or just “ARDS due to any cause.”
Since the coding was implemented, we found out that 7 percent of the transplants in the US have been for COVID-19. To go from not existing to becoming nearly 10 percent of the indication for transplant is pretty amazing.
How does a lung transplant operation for COVID-19 differ from lung transplants indicated for other causes?
We have our own experience of, I believe, six or seven patients that we transplanted here [at Columbia]. In COVID ARDS patients—who require ventilator and ECMO support, who require chest tube placement because they commonly develop pneumothoraces or lung collapse on both sides or either side and who develop recurrent bacterial or fungal infections because of either the indirect effects of severe viral infection or the treatments for it that are immunocompromising—in those patients, we found the surgery to be quite difficult, with severe adhesions of the lung to the chest wall and very bloody, difficult surgeries. Removing the lungs is difficult; the risk of bleeding is higher.
And then, the patients themselves are kind of marginal in that they've been hospitalized for a long time. They have musculoskeletal weakness. They commonly have other medical issues, whether it be kidney dysfunction or recent opportunistic infections. So, their course has been rather difficult.
We have had the ECMO cohort and we also have had the cohort of those who never required ventilators and high flow oxygen, and the latter does a little bit better.
Is there a difference in survival rates between COVID transplant patients and other lung transplant surgeries?
We don’t have long-term data for everybody yet, but in our analysis of the UNOS database, when you look at the three-month survival rate, COVID transplants do fairly well, actually, compared to the rest of the diseases. They have non-inferior survival at three months. This is not published yet, but hopefully, it will be accepted for publication and we could talk more about it formally. But they do okay.
I think the resource utilization is dramatically different and higher in COVID cases. The pre-transplant care, post-transplant care, longer hospital stay, longer ICU stay, and things like that are much higher. The economical cost of COVID transplant is unknown, but likely to be super high.
You mentioned there are more transplants recorded in the system for COVID-related ARDS than general ARDS. Are CARDS patients better candidates for transplant than patients with general ARDS? Why?
Yes. So, ARDS by definition means a severely ill patient on a ventilator and/or ECMO who's been in bed, not mobile, potentially sedated and paralyzed for some time, so that they could tolerate being on a ventilator. Traditionally, those patients were not considered to be great candidates for transplant, unless they were super young and thought to be salvageable. So, there are very few transplants reported in non-COVID ARDS cases from 2005 to 2020.
Once the COVID pandemic started, all of a sudden, we had lots of young to middle aged people in our hospitals who were stuck on a ventilator, and the paradigm shifted dramatically. We thought maybe this is something we could do.
We also have better support tools. For example, the improvements in ECMO compared to a decade ago have been dramatic. When on the ventilator, patients are typically uncomfortable, they need to be sedated. On ECMO support, they can be awake. We could keep people alive, and we could potentially get them physical therapy and do other things, because of ECMO support.
Due to that paradigm shift in our thinking, and better technologies, we started accepting these people little by little for transplant listing, and many of those patients ended up getting transplanted.
What else has changed or advanced in the science, technology, or just availability of lung transplants in the wake of COVID-19?
I think the culture change was really due to an unprecedented and devastating impact of COVID on numerous, relatively young people who have no other medical illnesses, who ended up with respiratory impariment, and without a transplant, dying. That caused a cultural shift in transplant candidacy as we know it. And that's resulted in us taking on these high-risk transplants, not just our program, but the rest of the world in places that do transplants.
In terms of the science, there hasn't been a direct impact related to transplantation, but obviously, we all observe the rapid progression of say, vaccine development or treatment trials and things like that.
I think COVID absorbed or sucked up a lot of resources from other medical fields because of the urgency that was needed. And in addition to that, we've been super busy because of COVID, because of resources that were pulled away. At the beginning of the pandemic, I was attending in the ICU to help my colleagues rather than performing transplant-related work because that's what had to be done.
I think we all experienced that a lot of the research studies had to be stopped or halted. So, it had a kind of a negative impact on other fields.
Over the last two years, some people have had to put off their routine or scheduled procedures and treatments because of reduced capacity due to COVID–does lung transplant for COVID impact patients awaiting transplant for different reasons?
Yes, for sure. When 7 percent of our indications come from a new disease, those patients displace others who are on the list or hoping to get on the list. The system by which transplant works, at least in the US and many parts of Europe, is a severity-based system for which a “lung allocation score” is used. Typically, COVID patients have very high lung allocation scores due to the fact that they're hospitalized, they're on life support. They rank immediately on top of their blood group, displacing or moving down others who are listed. We'll eventually find out the impact on waitlist mortality for other patients as more data comes along.
The good news is that all the transplant centers are more aggressive. Every year in the past maybe 10 years, there are more transplants being done, especially in the US. I think we topped 2,700-plus lung transplants a couple of years ago, just in the US. That number used to be 800 or 900 when I got in the field two decades ago. It’s a big, big change. So that may actually cancel out some of the adverse effects of COVID becoming a main indication.
Are there any differences in aftercare or management following COVID-related lung transplant? Is it the same immunosuppressant therapy any other transplant patient would receive?
We use the same medicine. There's nothing special about post- COVID lung transplant.
The main difference we've been experiencing is patient acceptance. I don't want to comment on compliance yet because we don't have that much experience. But imagine, these are previously healthy people who got thrown into transplant, and they wake up with new lungs, and they need to all of a sudden take 12 to 15 medicines for the rest of their lives, and they’re told to be careful, and that they're immunocompromised, and they're at risk of this and that. So, I think that's been rather difficult for patients and for us.
I would say that it's going fairly well because we do as much education as possible beforehand. And that's one of the major ethical issues related to COVID transplants: when do you consent patients for transplant? I think it's good to talk to patients and make sure they're okay with this. But there are some centers that get family consent because patients are sedated.
I hadn't thought of that! My understanding with transplant surgeries is that the patient needs to be very well prepared and counseled about management and being compliant after surgery. And sometimes that impacts how and when they receive an organ transplant, right? So it’s very different to think of somebody waking up to the world where they’ve had a transplant they didn't know would be happening.
Yeah, it is. We'll find out more as I think time goes by.
Can lung transplant recipients get vaccinated for COVID-19 the same as anyone else? If they've had a transplant, but they were not vaccinated ahead of time, can they still get vaccinated after?
They do get vaccinated after, actually, now they get four vaccines. Three is considered the primary series, fourth is the booster. And now, as you know, for even people like me above age 50, it's being recommended. Even if you're not a transplant recipient. But they do get vaccinated. The problem is that they don't develop an antibody response. And so the vaccine is not as protective.
We always prefer people to be vaccinated before, indeed NewYork-Presbyterian is now supporting a vaccine mandate for all transplant candidates.
Is there anything else that you want people to know about COVID treatment and lung transplant?
It’s the same message that sensical people have been giving for two years now. Being a transplant physician, I've seen it directly, and I lived it in the hospital for two years. The first three to six months were pretty scary for all of us. I mean, it was like dealing with a contagion like you see in the movies. Seeing all these people die, or eventually need a transplant, it's just: vaccination and protection.
People talk as if wearing a mask is a big deal, but compared to needing a lung transplant or losing a life, it's a small price that people should pay to protect one another and protect themselves. I sound like a broken record, but I'll say it again.