Case Series of Lung Transplants Done for COVID-19 Destroyed Lungs - Single Center Experience from India

PurposeFor patients with COVID 19 severe ARDS, lung transplant offers the only hope, if appropriate criteria are met.MethodsRetrospective analysis of 4 cases of bilateral lung transplant (LTx) at a private health facility between August to October 2020ResultsAll patients were male, with mean age of 52.1 years. The mean duration of ventilation before ECMO was 3 weeks. 3 patients had VV ECMO and one had a VA ECMO for circulatory collapse. This patient had previous coronary revascularization. The median duration on ECMO was 26 days. All patients were awake, involved in LTx discussion and actively rehabilitated. Profound myopathy was dominant in all. All had more than one episode of severe sepsis with Klebsiella pneumoniae and Acinetobacter requiring aggressive resuscitation and pressors. All had a trachestomy. Pneumothorax was treated with chest drains, 1 had hemothorax requiring thoracotomy. The lung was found to be extremely friable with dense adhesions in 3 with excessive chest wall bleeding. The ECMO was weaned off in all patients, 2 in the operating room and 2 in the ICU after 48 to 96 hours. The patient with CAD required VA ECMO due to transient left ventricular dysfunction. All patients could be weaned off the ventilator with excellent lung function breathing room air. The patient with CAD had Elizabeth meningoseptica septic shock in the late post op period with multi organ failure and death, while the other 3 are recovering and undergoing physical rehabilitation.Histology of the lungs showed alveolar damage, interstitial fibrosis with mononuclear infiltration, vasculitis and organizing fibrin thrombi, even in larger blood vessels. Electron microscopy showed absence of surfactant producing lamellar bodies in alveocytes, extensive mitochondrial damage and disrupted vascular endothelial lining with thrombus (Fig 1)ConclusionLung transplant is a viable option for selected patients of COVID-19 who do not recover lung function despite optimal medical care and have life threatening complications. For patients with COVID 19 severe ARDS, lung transplant offers the only hope, if appropriate criteria are met. Retrospective analysis of 4 cases of bilateral lung transplant (LTx) at a private health facility between August to October 2020 All patients were male, with mean age of 52.1 years. The mean duration of ventilation before ECMO was 3 weeks. 3 patients had VV ECMO and one had a VA ECMO for circulatory collapse. This patient had previous coronary revascularization. The median duration on ECMO was 26 days. All patients were awake, involved in LTx discussion and actively rehabilitated. Profound myopathy was dominant in all. All had more than one episode of severe sepsis with Klebsiella pneumoniae and Acinetobacter requiring aggressive resuscitation and pressors. All had a trachestomy. Pneumothorax was treated with chest drains, 1 had hemothorax requiring thoracotomy. The lung was found to be extremely friable with dense adhesions in 3 with excessive chest wall bleeding. The ECMO was weaned off in all patients, 2 in the operating room and 2 in the ICU after 48 to 96 hours. The patient with CAD required VA ECMO due to transient left ventricular dysfunction. All patients could be weaned off the ventilator with excellent lung function breathing room air. The patient with CAD had Elizabeth meningoseptica septic shock in the late post op period with multi organ failure and death, while the other 3 are recovering and undergoing physical rehabilitation.Histology of the lungs showed alveolar damage, interstitial fibrosis with mononuclear infiltration, vasculitis and organizing fibrin thrombi, even in larger blood vessels. Electron microscopy showed absence of surfactant producing lamellar bodies in alveocytes, extensive mitochondrial damage and disrupted vascular endothelial lining with thrombus (Fig 1) Lung transplant is a viable option for selected patients of COVID-19 who do not recover lung function despite optimal medical care and have life threatening complications.