Just 12 hours after undergoing a double-lung transplant, 70-year-old Francisco Medellin was sitting up in a chair pushing bike pedals – a seemingly simple act that was the culmination of hard work by a dedicated multidisciplinary team from McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth).
UTHealth surgeons, critical care specialists, infectious disease experts, pulmonologists, anesthesiologists, and nurses worked together to make possible the first double-lung transplant in Texas and one of only a handful in the country.
“This is a huge milestone as one of the first few double-lung transplants in the country,” said Biswajit Kar, MD, co-chief of the Center for Advanced Cardiopulmonary Therapies and Transplantation (ACTAT) at UTHealth and Memorial Hermann-Texas Medical Center. “As we show to the world that this is an option, it will open up possibilities for more COVID-19 patients.”
Medellin contracted the virus in June. By the time he was referred to Memorial Hermann-TMC for treatment from the UTHealth transplant team, doctors at Memorial Hermann-The Woodlands had already tried the available therapies – convalescent plasma with antibodies from recovered patients, steroids, and the investigational drug remdesivir. But Medellin’s infection-induced pneumonia and acute respiratory distress syndrome continued to worsen.
“He was breathing pure oxygen and yet his oxygen saturation levels were barely in the normal range,” said Soma S. Jyothula, MD, associate professor of medicine with McGovern Medical School and the critical care physician for the ACTAT team. “He wasn’t getting any better and it was evident he had severe lung damage that wasn’t healing. His lungs were no longer compatible with life.”
In the operating room, it became clear that the damage to Medellin’s lungs was extensive.
“There was more inflammation than what we usually see in a patient who is being transplanted. They were boggy, heavy, and had extensive lesions,” said Manish K. Patel, MD, associate professor of medicine at McGovern Medical School, who performed the surgery.
The lung allocation score, which determines placement to receive a lung transplant, ranges from 0 to 100, with 100 being the highest. Medellin’s score was 78.
“He was a good candidate. He was young and healthy except for the infection and it was a single organ dysfunction with the lungs. He could have a good, productive life if the lungs were replaced,” Kar said. “He is a hardworking guy with great family support, so we knew he would do the rehabilitation.”
In fact, even pre-surgery while he was in the intensive care unit (ICU) and on nearly 100% oxygen, Medellin was still doing bedside physical therapy, Jyothula said.
To make sure the virus had cleared Medellin’s body, necessary to qualify him for a transplantation, infectious disease experts were brought in. They also had to confirm that the donor did not have COVID-19.
“From the donor side, there are no guidelines for COVID-19, so we had to come up with our own,” said Luis Z. Ostrosky, MD, professor of infectious disease at McGovern Medical School. “When you’re getting lungs from a donor where there’s COVID-19 within the community, you need to make sure the donor is not infected with absolute certainty. Our rule: rapid PCR test the donor lungs in addition to another standard PCR test with a longer turnaround time.”
While Kar and Igor D. Gregoric, MD, co-chief and program co-director of ACTAT, have been steadily building a successful lung transplant program for four years, transplanting COVID-19 patients is rare around the world.
“The virus is such a new thing that we don’t fully understand,” Gregoric said. “With COVID-19, we have quite a large number of people who are very sick, and the sickest of them we’ve been able to treat in the ICU and place them on ECMO as a last resort. Despite these drastic measures, some of them might not survive.”
Although not requiring ECMO – extracorporeal membrane oxygenation – Medellin’s lungs were so destroyed by the virus that the medical review board decision was made to place him on the transplant list, and within 24 hours he was matched with a donor at Memorial Hermann-TMC.
“It was very fortunate we were able to find a donor that quickly for this patient. We want to thank this grieving family who in the midst of their loss was willing to help another family,” Gregoric said.
The surgical team team included cardiovascular anesthesiologist Warren Choi, MD, assistant professor in the Department of Anesthesiology at McGovern Medical School. "Lung transplant is one of the most challenging anesthesia cases and an essential step towards the success of the surgery," said Yafen Liang, MD, associate professor of anesthesiology and chief of the Division of Cardiovascular Anesthesiology. "This requires comprehensive planning and close communication with the transplant surgeon."
Physicians noticed the change immediately after surgery.
“The minute he came out, his lungs looked fantastic,” said Bindu Akkanti, MD, associate professor of critical care at McGovern Medical School and medical director of the Heart Transplant Intensive Care Unit at Memorial Hermann-TMC. “We took out the breathing tube, and he was so motivated to get out of the bed. The same day of his surgery, he was riding the rehabilitation bike.”
Within a few days, Medellin was taken off all supplementary oxygen. He was discharged to rehabilitation after 11 days and now, in his second week of rehabilitation, he is already climbing stairs after being bedbound for more than two months.
“In the beginning we didn’t really think that lung transplant could play a role in COVID-19 treatment, but when death is the only alternative, we have to push modern science,” Akkanti said.
“This success story is only possible because of the excellent multidisciplinary work by our team of experts,” Ostrosky said. “From cardiopulmonary to infectious disease, critical care, and surgery, this was uncharted territory for us, but by working together with all the individual expertise we had, this patient had a great outcome.”
Kar said this procedure could also become important for coronavirus “long haulers” who are dealing with the aftereffects months after their active infection.
“This will also be important for patients with lingering effects of the virus since so much is unknown,” Kar said. “If they have lung damage that manifests later with life-limiting symptoms, they also might need a lung transplant.”
Jyothula is the medical director and Patel is the surgical director of the lung transplant program at Memorial Hermann-TMC. Ostrosky is medical director for epidemiology and antimicrobial stewardship for Memorial Hermann-TMC and UT Physicians, and he is currently coordinating the COVID-19 response for UTHealth and its affiliate hospitals and clinics. UT Physicians is the clinical practice of McGovern Medical School.
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