Lung Transplants Successful in Patients with COVID-19-Associated ARDS

A new investigation from Illinois into patients with COVID-19-associated acute respiratory distress syndrome (ARDS) found that the survival rate for those who underwent a lung transplant was 100%.

Investigators noted that between 6% and 10% of patients with COVID-19 eventually progress to ARDS and require mechanical ventilation, and that the mortality rate of patients with COVID-19-associated ARDS could potentially exceed 20% to 40% in the near future.

The investigative team led by Chitaru Kurihara, MD, Division of Thoracic Surgery at Northwestern University, Chicago, hypothesized that lung transplantation could be a potentially lifesaving treatment for patients who were critically ill from COVID-19-assoviated ARDS, and set out to report the clinical characteristics and outcomes from affected patients.

The Methods

Investigators performed a retrospective case series at Northwestern University Medical Center in Chicago, and all patients who underwent a lung transplant between January 21, 2020, and September 30, 2021, were enrolled.

All patients without COVID-19 signed a consent form for a lung transplant, and 29 of the 30 patients with COVID-19–associated ARDS consented to the surgery.

A multidisciplinary team of surgeons, infectious disease physicians, pulmonary and critical care physicians, and cardiologists were present to treat all patients with COVID-19-associated ARDS.

Prior to the lung transplant, all intubated patients were treated by a multidisciplinary team in accordance with guidelines from the National Heart, Lung, and Blood Institute’s ARDS Network.

Demographic, clinical, laboratory, and treatment data were collected and analyzed prior to the transplant, followed by outcomes of the lung transplant that included postoperative complications, intensive care unit and hospital length of stay, and survival.

The Findings

Investigators enrolled a total of 102 lung transplant recipients. Among these patients, 30 (median age, 53 years; 13 women [43%]) had COVID-19–associated ARDS and 72 patients (median age, 62 years [range, 22 to 74]; 32 women [44%]) had chronic end-stage lung disease without COVID-19.

For lung transplant recipients with COVID-19 the median lung allocation scores were 85.8 vs 46.7 compared with those without COVID-19.

The median time on the lung transplant waitlist was 11.5 vs 15 days, and preoperative venovenous extracorporeal membrane oxygenation (ECMO) was used in 56.7% vs 1.4%, respectively.

During transplant, patients who had COVID-19–associated ARDS received transfusion of a median of 6.5 units of packed red blood cells vs 0 in those without COVID-19, 96.7% vs 62.5% underwent intraoperative venoarterial ECMO. The median operative time was 8.5 vs 7.4 hours, respectively.

Post-operatively, the team noted the rates of primary graft dysfunction (grades 1 to 3) within 72 hours were 70% in the COVID-19 cohort vs 20.8% in those without COVID-19, while the median time receiving invasive mechanical ventilation was 6.5 vs 2.0 days.

Additionally, the median duration of intensive care unit stay was 18 vs 9 days and the median post–lung transplant hospitalization duration was 28.5 vs 16 days, and 13.3% vs 5.5% required permanent hemodialysis, respectively.

None of the lung transplant recipients who had COVID-19–associated ARDS demonstrated antibody-mediated rejection compared with 12.5% in those without COVID-19.

During the follow-up period, all 30 lung transplant recipients who had COVID-19–associated ARDS were alive (median follow-up, 351 days [IQR, 176-555] after transplant) as opposed to 60 patients (83%) who were alive in the non–COVID-19 cohort.

"With advanced ventilatory and extracorporeal support, more than 50% to 60% of patients with COVID-19–associated ARDS can demonstrate lung recovery," the team wrote.

The study, "Clinical Characteristics and Outcomes of Patients With COVID-19–Associated Acute Respiratory Distress Syndrome Who Underwent Lung Transplant," was published online in JAMA Netowrk.