Lung transplant surgery for corona pneumonia

I would like to introduce the story of a patient who lost both lung functions due to COVID-19 and was between life and death, and the patient was discharged from the hospital without complications after a successful lung transplant. After being diagnosed with COVID-19 in December last year, the patient suffered severe lung damage on both sides and was unable to breathe on his own, but he recovered his health through a lung transplant in February this year and was discharged safely on the 2nd of this month, 12 days after the surgery.

From left, Prof. Seokjin Ham, Department of Cardiothoracic Surgery, Ajou University Hospital, and Prof. Jieun Park, Department of Pulmonology, Department of Pulmonology

Hello PD = Professor. Please introduce yourself.

Prof. Seokjin Ham = My name is Seokjin Ham and I am in charge of lung transplantation at the Department of Thoracic Surgery at Ajou University Hospital.

Prof. Jieun Park = Hello. This is Jieun Park, who is looking at a lung transplant patient with intensive care in the Department of Pulmonology at Ajou University Hospital.

# 55-year-old male patient with no respiratory-related diseases, from COVID infection to decision to lung transplant surgery

Lee Go-eun PD = You told us that you had a successful lung transplant this time, but I am curious about the preoperative condition of the patient who received a lung transplant this time. When was your first admission to the hospital, and how was your overall health?

Prof. Ham Seok-jin = The patient was a 55-year-old man, who was infected with COVID-19 through a relative in mid-December last year and was confined to an isolation facility, but his condition deteriorated rapidly and he was admitted to the Department of Infectious Diseases at Ajou University Hospital on December 24. The patient's overall health condition was that he had no other medical conditions other than diabetes, and he had never been seen for a respiratory condition.

PD = How did the COVID treatment process go before the patient received a lung transplant?

Prof. Park Ji-eun = When the patient came to the hospital, he had already complained of severe shortness of breath, and his oxygen saturation level dropped rapidly, and he started ventilator treatment. However, her condition continued to deteriorate even with ventilator treatment, so she started ECMO therapy, which provides oxygen through extracorporeal circulation. Fortunately, she stabilized after 3 weeks of ECMO treatment, but her condition continued to improve and worsen after that. Therefore, various treatments were performed, including rehabilitation treatment, but the patient's condition did not improve anymore and worsened, and it was judged that the patient's lung function could no longer be restored due to severe sequelae due to pneumonia caused by COVID-19, so we decided to have a lung transplant after about 2 months of ECMO treatment.

Prof. Ham Seokjin = The patient put ECMO in and out 3 times, but in the end, he couldn't take it out and went to the transplant. On February 21st, we finally decided to have a lung transplant and registered with KONOS (Organ Transplant Center), but luckily, we were able to find a donor lung in 5 days, so we performed a bilateral lung transplant on February 26th.

# Corona Lung Transplant Overseas Cases

Lee Go-eun PD = You said that you searched a lot of overseas cases and studied a lot to prepare for surgery, but what about overseas cases? And wasn't this operation difficult?

Prof. Ham Seok-jin = Currently, lung transplantation has just started on patients who have deteriorated into severe illness after the outbreak of Corona, so even if all the cases in each country are collected, there are not many cases. Normally, if you try to give medical statistics, you need at least a few dozen cases to know the prognosis and problems with the surgical process, but as it stands now, there are no cases of transplantation in Corona patients on a large scale, so we could only find them through case reports. Results were reported in March for 12 patients who received lung transplants for COVID at The Lancet, and the results were not lower than those who received lung transplants for other common conditions.

If you look for cases, it is said that in the case of corona patients, pleural adhesions occur a lot because it is an infectious disease. It is difficult to remove the lung that I originally had during surgery because the pleura with the lungs and ribs is attached, and there is a lot of blood during the surgical process, and the lung crest where the lungs are attached to the body is also very inflamed, so it is difficult to remove and attach the blood vessels in that part during surgery. So I didn't have to worry too much about bleeding during the surgery, but I had to be careful when dissecting the blood vessels because I had severe sclerosis in the lung area. Our patient had a clean pleura, so the surgery was easier than I thought without any difficulties or problems.

Lee Go-eun PD = Recently, it was reported that live lung transplantation was performed on corona lung transplant patients in Japan, what is the trend of living lung transplantation in Korea?

Prof. Ham Seok-jin = Living lung transplantation in Korea is legally permitted, so it is possible if it is necessary and suitable, but there are no satisfactory transplant results so far. In order to receive a living lung, you must donate the lungs of a healthy family member, so it may be ethically problematic to donate the lungs of a healthy person to an unhealthy person. In the case of Japan, it is more difficult to transplant organs from brain-dead people due to various legal problems, so living lung transplantation was developed, and Kyoto University, which succeeded in transplanting living lungs this time, is famous for its living lung transplants all over the world, so it is thought that it was easy to perform the surgery.

# CORONA PNEUMONIA VS. GENERAL PNEUMONIA, FATALITY AND CONTAGIOUSNESS ARE DIFFERENT, BUT SURGERY IS NOT MUCH DIFFERENT

PD = Normal pneumonia and corona pneumonia are different, but how is the progression rate, fatality, and contagiousness different? And can these factors affect the transplant procedure?

Prof. Jieun Park = There are many different aspects of general pneumonia and corona pneumonia. The main difference is that sometimes corona pneumonia has no symptoms. Even if it progresses, it may progress slowly, while in some patients it may progress rapidly. On the other hand, when general pneumonia develops, symptoms such as fever, cough, and sputum appear immediately, so patients come to the hospital, and there are medicines available to treat this pneumonia, so if treated at the right time, most of the time, even if it progresses rapidly, many parts can improve. Corona pneumonia is often not known to patients when there are no symptoms, but when symptoms suddenly appear and tests are performed, it is often already very advanced, and in such cases, it can worsen into severe pneumonia.

Lung transplantation is considered when there are serious sequelae from general pneumonia or corona pneumonia, and there is usually a period of preparation for lung transplantation because there are many patients with chronic lung disease. Therefore, if there is no improvement despite active treatment, the patient will go through the process of deciding and preparing for lung transplantation, but in the case of corona pneumonia patients, there is no such preparation time, and if the patient's condition worsens, lung transplantation must be discussed immediately, so this is a difficult part of the lung transplant preparation process, unlike general pneumonia patients.

Just because PD = Corona pneumonia doesn't mean that the progression or contagiousness of the surgery will affect the outcome of the surgery, right?

Prof. Park Ji-eun = Even if it is Corona pneumonia, lung transplantation is not considered when pneumonia is in progress. Lung transplantation is discussed when the patient does not improve despite sufficient treatment, or if the lung function is not maintained due to severe scarring after treatment. When the coronavirus is still in full swing in the lungs, even if you receive healthy lungs, the virus will continue to attack your lungs and you may not consider a transplant at that stage. In other words, when a transplant is considered, if the COVID treatment has progressed sufficiently, and the patient is unable to survive because the patient is no longer able to maintain lung function due to severe scarring during the recovery stage, then lung transplantation will be discussed.

Prof. Seokjin Ham = When choosing a lung transplant, the possibility of recovery should be fully considered. Nowadays, the guidelines say that you should wait for 4~6 weeks before deciding on a lung transplant, and if you decide that there is no possibility of recovery after that, you should decide on a transplant.

When PD = COVID infection, are there any high-risk groups that can worsen into severe pneumonia?

Prof. Park Ji-eun = Apparently, the state of one's health affects a lot, and this is the same with pneumonia in general. If your immune system is well maintained, you can overcome the virus, but the elderly or those with underlying diseases who usually have a weak immune system may not be able to overcome the virus well. Therefore, people with underlying diseases, the elderly, and infants are considered to be at high risk. In addition to this, even young people who did not have any underlying diseases and were healthy may develop severe pneumonia due to COVID. The reason for this is not yet known, but there are many opinions that "Corona pneumonia does not affect the immune system differently from regular pneumonia," and related research is being conducted.

PD = The patient received a lung transplant and was discharged from the hospital in good health without any complications. What was your chance of success before your surgery?

Prof. Ham Seokjin = Actually, I didn't think that just because I was a corona patient, my surgery performance would be bad. I thought it would be the same as a conventional lung transplant surgery. When I treated them this time, I found that patients who underwent lung transplantation due to chronic lung disease suffered from the disease for a long time and had a long hospital stay, so the patient's physical strength was much reduced, so the physical strength was weaker. On the other hand, since Corona progresses acutely, people who are usually healthy often deteriorate within a short period of time, so it seems that the physical strength to endure the transplant is better. So, when I look at rehabilitation and recovery periods, I often feel that I recover much faster than I do with chronic diseases.

And in the case of 12 patients published in The Lancet, one died two months after the operation. The rest of the patients are still surviving for 1~6 months, although the follow-up period of surgery is still short. Therefore, you can think of the results of Corona lung transplantation as almost the same as that of a general lung transplant.

The left side is before the lung transplant operation, and the right side is after the lung transplant operation.

Prior to surgery, the pneumonia was severe, and the bilateral lungs appeared white, and after the transplantation of healthy lungs, the lungs appeared dark.

Also, I would like to tell you about the progress of lung transplant patients after surgery, and in overseas cases, if you enter the operating room with ECMO before lung transplant surgery, about 80% of patients will wear ECMO after surgery. However, our patient came out with the ECMO removed. Normally, ventilators are used for an average of two weeks, but our patients were only on them for five days. The length of stay in the intensive care unit was 12 days (an average of 20 days). The patient was bleeding so much after the surgery that several more surgeries were performed, but fortunately, despite the bleeding, the patient survived and was able to leave the hospital in a shorter period of time than expected, 35 days.

Prof. Jieun Park = I feel the same way. Because of the patient's usual good health, even if he had been treated in the intensive care unit for a long time, he was able to do so in his bed, even though he had been bedridden for two months. In addition, when I encouraged the patient, he had a strong will to recover, and his family members also gave him encouragement and support. Therefore, I thought that this patient would be able to recover his daily life if he received a transplant.

PD = So, who in the group of patients with corona pneumonia can receive a lung transplant? What are the indications?

Prof. Seokjin Ham = In our opinion, we should follow the general guidelines for lung transplantation now. If you are under the age of 65, if there is no damage to other organs, if it is clearly determined that there is no possibility of recovery, you may be a candidate for a lung transplant if you have been treated with medication for at least 4-6 weeks and if it is determined that there is no possibility of recovery.

# Discharged from the hospital in good health after 35 days of surgery, the patient's will and the support of the family are the most important for recovery

PD = When was the last time you met with this patient? How has your condition been recently?

Prof. Seokjin Ham = I met him today. You are in a wheelchair today, and you can get up if we help you get up, and when you get up, you can walk around on your own. He had a lot of strength to get up, and he didn't seem to have enough strength to get up, and he had no problem walking.

 

Prof. Jieun Park = I last met him yesterday. I asked him how he was doing at home, and he said that he was able to walk a few steps on his own, and that he was able to walk a little longer with the help of someone.

PD = When do you think your lung function will be fully restored and what activities will you be able to do after recovery? Is it possible to run, hike and do these kinds of things?

Prof. Ham Seokjin = It depends on your own efforts, but if you say that the recovery effect after the transplant is good, you can return to your daily life after a few months. Of course, you can also run and hike. Some of the patients I've seen have recovered from a lung transplant and are even amateur table tennis players.

PD = You've recovered completely healthy! So, is there anything this patient should be aware of in the future?

Prof. Seokjin Ham = First of all, the most important thing for a patient after a lung transplant is rehabilitation. How quickly the patient recovers depends on the patient's efforts, so the most important thing to ask is to exercise hard and adjust your diet. In particular, this patient has diabetes, so it is important to adjust his diet. And since the support and encouragement of family members plays an important role in transplant performance, the bond with family members is also important.

# There is no clear cure for Corona yet. Prevention is everything. You must also get vaccinated...

With patients and medical staff in the hospital room (Courtesy of Ajou University Hospital)

PD = Lastly, you have treated patients with severe corona pneumonia, and please tell us what you would like to say as a medical staff who will treat them in the future.

Prof. Park Ji-eun = There is still no clear cure for the coronavirus. There are many treatments for severe pneumonia, but there is no one that really works, and lung transplantation is the next best option when there is no longer recovery from these treatments. Even if you have a lung transplant, you will not recover unconditionally, and there are complications and risks associated with it, so the most important thing is to be careful and prevent infection with Corona. Since no cure has been developed yet, it seems that the most important thing is to be careful while following the quarantine rules.

And you have to get a vaccine, which is the process of building up your immune system to fight the coronavirus when it enters your body. Therefore, it is important to check if your physical condition is good enough to receive the vaccine and get it when it is good, rather than getting it as soon as possible. And getting vaccinated will definitely help.

PD = If you have anything you can't say, feel free to tell us more.

Prof. Park Ji-eun = Actually, in the case of this patient, his life was in danger because he developed severe pneumonia at the beginning of the corona infection, and it was a very unfortunate situation at that time. All my family members were infected with Corona, so they were all in quarantine, so I couldn't see the patient's condition. This is not only for our patients, but also for other corona patients, who in principle are not allowed to visit them, and the only thing that can be done is to see the patients through CCTV footage. What is really unfortunate when there are patients who are nearing the end of their lives is that they cannot touch their hands or watch them close up. Family members can only check the patient's condition through video. However, when our patient was really critical, his family was also in quarantine due to Corona, so it was difficult to even check the video. So we were only able to communicate the patient's condition over the phone, but fortunately, the patient recovered, and I think the family's joy is a little greater in that regard.

Prof. Ham Seokjin = He came here today and was very proud of his son.

I will continue to support the patient for his recovery so that he can be proud of PD = son more, and I will continue to support the Ajou University lung transplant team in the future. I appreciate it.