When Dr. Edward Sako attended medical school in the late 1980s, lung transplant surgeries were rare and, of course, COVID-19 was unknown.
By the time he completed his residency in thoracic surgery in 1992, University Health had one of the first transplant programs in the country to treat patients with terminal respiratory disease. Sako has performed hundreds of lung transplants since then.
Backed by a team of surgeons, physicians, and nurses, Sako in October performed the first local double-lung transplant on a San Antonio patient whose lungs were so damaged from acute respiratory disease caused by the novel coronavirus that doctors were left with few options.
“Transplant and lung transplant, in particular, is … a treatment of last resort when you’ve pretty much exhausted everything else,” said Sako, chief of cardiothoracic surgery, surgical director for University Health’s lung transplant program, and a faculty member at UT Health San Antonio.
The transplant recipient, who doctors said does not want to be identified, is reported to be recovering well. The patient is among fewer than 30 people nationwide to undergo lung transplants due to COVID-19, Sako said, a small number considering nearly 75,000 have been hospitalized with the virus since March. The first successful double-lung transplant in the U.S. was in June.
Prior to the coronavirus pandemic, lung transplants were reserved for patients with progressive lung diseases such as chronic obstructive pulmonary disease (COPD), cystic fibrosis, pulmonary hypertension, and interstitial lung diseases caused by exposure to hazardous materials or an autoimmune disease.
Donor lungs are harder to come by than other organs such as livers and kidneys, and lung transplants remain one of the riskiest of all types of transplant surgeries. The incidence of rejection and infection is high.
“One simple explanation [for poor outcomes] is that you’ve immunocompromised the patient, and yet they have lungs that are exposed to the outside environment simply by the act of breathing,” Sako said. “When you look at the survival rate after five years, we know that lung [transplants] are not as good as the other organ systems.”
Sako said the transplant team at University Health has had mostly “good outcomes” performing more than 700 lung transplants.
But unlike patients hospitalized with COVID-19, patients with chronic lung diseases become aware over the course of several years that they will need transplant surgery, said Dr. Debbie Levine, medical director for the University Health lung transplant program who is also a faculty member at UT Health San Antonio.
“So this type of disease state which comes on unexpectedly, as well as is pretty rapid, is a different type of scenario,” she said of COVID-19.
In severe cases of COVID-19, patients get viral pneumonia, which is complicated by a release of inflammatory cells and inflammatory markers, Levine said. That can progress to acute respiratory distress and the patient needing to be on a ventilator or ECMO (extracorporeal membrane oxygenation) in order to survive.
At that point, the patient may improve, Levine said, “which we all hope for each one of them, but oftentimes the process may not be reversible” and the lungs are left scarred and damaged.
In the case of the recent lung transplant Sako performed, the COVID-19 patient’s lungs resembled those of a patient with interstitial lung disease: scarred and inflamed.
“The [coronavirus] patients that are considered for lung transplant are ones that … are needing some additional level of support, and it’s pretty clear partly from the amount of time that they’ve been receiving treatment that things just aren’t going to get better and that they, in general, reach the stage where the lungs are just so scarred up, they just are not going to recover,” Sako said.
But not every such patient is a candidate for a lung transplant; it’s important that other organs and systems have not been damaged by the coronavirus. Though COVID-19 is caused by a respiratory virus, it’s widely believed to be a cardiovascular disease that can attack multiple systems in the body.
The team at the University Health System Transplant Center looks for the patient to be strong enough to stand and walk, and able to understand the risks and potential outcomes of a lung transplant in order to consent to the surgery.
That leaves few who are considered for the surgery, Sako said. “It’s not that we wouldn’t like to offer it to a lot of people but we’re trying to make our best judgment as to who’s going to do well after the transplant,” he said.
Another group of patients the team sees from the post-COVID clinic are those who survived, have been discharged from the hospital, and are at home recovering.
“Maybe they’ve plateaued with regards to how much they can do and then they end up presenting like a lot of other patients with interstitial lung disease,” Sako said. “We haven’t really seen that yet, but we anticipate that might happen.”
But there’s still much that doctors don’t know about the coronavirus and its lasting effects. Sako said it’s possible that people who initially don’t have many symptoms could have problems later on with lung disease tied to an infection.
“We’re learning as we go,” Levine said. “And we’ll look back maybe in five years [or] maybe two years and see where we’re at, but at this time last year, we didn’t even know the word.”