key: cord-0732574-2u7a11k3
authors: Ohsumi, Akihiro; Takamatsu, Jumpei; Yuasa, Itsuki; Tanaka, Satona; Yutaka, Yojiro; Hamaji, Masatsugu; Nakajima, Daisuke; Yamazaki, Kazuhiro; Nagao, Miki; Date, Hiroshi
title: Living-Donor Lung Transplantation for Post-COVID-19 Respiratory Failure
date: 2021-11-05
journal: Ann Thorac Surg
DOI: 10.1016/j.athoracsur.2021.10.003
sha: b1f941afa88f5dd3fb0e5e7555a5879e0339a2bd
doc_id: 732574
cord_uid: 2u7a11k3

We report the first case of coronavirus disease 2019 (COVID-19)-associated respiratory failure requiring urgent living-donor lobar lung transplantation (LDLLTx). A 57-year-old woman with a positive viral status developed severe hypoxia requiring extracorporeal membrane oxygenation (ECMO). Her respiratory function deteriorated, with almost totally collapsed lungs. All of her other organs functioned well. After 104 days on ECMO, she received urgent LDLLTx under cardiopulmonary bypass. The grafts worked well, and she was weaned off cardiopulmonary bypass after reperfusion. LDLLTx is an option for selected patients with post-COVID-19 end-stage respiratory failure. Coronavirus disease 2019 (COVID-19) has spread worldwide since December 2019 due to the unprecedented pandemic.1 Patients with end-stage COVID-19-related respiratory failure require mechanical ventilation and/or extracorporeal membrane oxygenation (ECMO). In some countries, lung transplantation (LTx) has become a treatment option for irreversible lung function deterioration.2,3 We report the first successful case of severe respiratory failure caused by COVID-19 treated with urgent living-donor lobar lung transplantation (LDLLTx).

We report the first case of coronavirus disease 2019 (COVID-19)-associated respiratory failure requiring urgent living-donor lobar lung transplantation (LDLLTx). A 57-year-old woman with a positive viral status developed severe hypoxia requiring extracorporeal membrane oxygenation (ECMO). Her respiratory function deteriorated, with almost totally collapsed lungs. All of her other organs functioned well. After 104 days on ECMO, she received urgent LDLLTx under cardiopulmonary bypass. The grafts worked well, and she was weaned off cardiopulmonary bypass after reperfusion. LDLLTx is an option for selected patients with post-COVID-19 endstage respiratory failure.

J o u r n a l P r e -p r o o f Coronavirus disease 2019 (COVID-19) has spread worldwide since December 2019 due to the unprecedented pandemic. 1 Patients with end-stage COVID-19-related respiratory failure require mechanical ventilation and/or extracorporeal membrane oxygenation (ECMO). In some countries, lung transplantation (LTx) has become a treatment option for irreversible lung function deterioration. 2, 3 We report the first successful case of severe respiratory failure caused by COVID-19 treated with urgent living-donor lobar lung transplantation (LDLLTx).

A 57-year-old woman without any past medical history experienced body weakness, reduced level of consciousness, and difficulty in walking. She was admitted to a local hospital via the emergency department. Her SpO2 level was 78% with reservoir mask oxygen (10 L/min). Chest radiography showed generalized opacities over the lung fields (Fig. 1A) . Chest computed tomography (CT) showed bilateral pulmonary opacification with ground-glass opacities and dense consolidation in the ventral and dorsal lung fields, respectively ( Fig. 2A, B) . She was intubated and mechanically ventilated immediately; however, her PaO2 with pure oxygen was 57 mmHg. She was diagnosed with severe acute respiratory distress syndrome (ARDS) related to COVID-19 based on positive results of the polymerase chain reaction for SARS coronavirus 2.

Consequently, ECMO was established via inflow cannulation of the right jugular vein and outflow cannulation of the left femoral vein. Repeat chest radiography (Fig. 1B) and CT (Fig. 2C, D) performed three months after admission revealed exacerbation of lung damage, which was considered irreversible, but all of her other organs functioned well. She was subsequently referred to our team; we deemed the patient to be a candidate for LDLLTx after evaluation.

Potential donors were evaluated, and we concluded that her husband and son were suitable living donors after careful deliberation. Functional size matching calculated using forced vital capacity was 79%. She was transferred to our hospital under ECMO 102 days after admission to the local hospital. The patient was alert and awake and the donors were counseled appropriately J o u r n a l P r e -p r o o f regarding the risks and benefits of LDLLTx. Informed consent was obtained from the recipient and both donors. The lungs, which were exposed through the clamshell incision, appeared almost completely shrunken and collapsed (Fig. 3A) . Cardiopulmonary bypass (CPB) was established after full heparinization; a dual-stage cannula was inserted into the right atrium, an arterial cannula was inserted into the ascending aorta, and a vent was placed into the pulmonary trunk. Subsequently, the preexisting ECMO circuit was removed. The patient's son's right lower lobe and her husband's left lower lobe were procured, and both grafts were flushed with ET-Kyoto solution under ventilation. Both pneumonectomies were performed, and the procured lower lobes were implanted, then ventilated and reperfused (Fig. 3B) . She was smoothly weaned off CPB, and the circuit was removed. The chest was tentatively closed using a Gore-Tex soft tissue patch because the tidal volume dropped with direct closure. The total graft ischemic time was 226 and 148 min in the right and left lungs, respectively. The PaO2 on ICU admission was 441 mmHg with 100% oxygen inhalation. On POD 2, the chest was closed completely. The grafts worked very well; however, the patient was weaned off the ventilator after 2 months probably due to weakness of the respiratory muscles. Four months after LDLLTx, she was doing well without any episode of infection or rejection (Fig. 1C) . She could walk for 150 m, and was transferred to the local hospital for further rehabilitation. Histopathological examination of the resected lung specimens showed pulmonary fibrosis, focal alveolar hemorrhage, and organized thrombosis of the pulmonary artery.

To our knowledge, this is the first report of a patient with end-stage post-COVID-19 respiratory failure who underwent LDLLTx. An international survey conducted in 2020 reported that 81% centers declared a reduction in LTx rates. 4 In our country, donor shortage is severe, and LDLLTx was thought to be the only method to rescue this patient. 6 The implanted lower lobes were still larger than our patient's shrunken chest cavities, necessitating delayed chest closure (Fig. 3B) . From this standpoint, LDLLTx may be suitable for patients with COVID-19-related lung failure.

Ahmadi et al. reported that a hypercoagulable state and oxygenator failure were the most important etiologies for venovenous (V-V) ECMO failure in patients with COVID-19. 7 Our patient also required recurrent circuit changes, had thrombus formation in the large veins despite controlled heparinization, and the explanted lungs showed pulmonary artery thrombosis.

Guihaire et al. stated that high blood flow and anticoagulation at levels higher than conventional practice may be required for V-V ECMO in patients with COVID-19-related ARDS because of the thrombotic hematologic profile of COVID-19. 8 Bharat et al. reviewed the intraoperative configuration in a consecutive case series. They reported that all procedures were performed using central venoarterial ECMO support, and pretransplant V-V ECMO was empirically continued after transplantation in anticipation of a high risk of primary graft dysfunction. 3 We considered the possibility of embolization during decannulation of the current ECMO cannulae, which were placed three months ago. Therefore, we decided to establish CPB anew and removed the V-V ECMO before explanting the native lungs.

LDLLTx may be a possible treatment option for patients with post-COVID-19 end-stage respiratory failure. 

Clinical characteristics of coronavirus disease 2019 in China

Lung transplantation for pulmonary fibrosis secondary to severe COVID-19

Early outcomes after lung transplantation for severe COVID-19: A series of the first consecutive cases from four countries

Management of lung transplantation in the COVID-19 era-An international survey

When to consider lung transplantation for COVID-19

Lung transplantation for coronavirus disease 2019 (COVID-19): The who, what, where, when, and why

Extracorporeal membrane oxygenation and COVID-19: The causes of failure

Specific considerations for venovenous extracorporeal membrane oxygenation during coronavirus Disease

J o u r n a l P r e -p r o o f