10 Hours of Uncertainty
Published July 2021
20 Recipients of Double-Lung Transplants Following COVID-19
They hadn't thought much about death because they were otherwise healthy. Suddenly, dying was a possibility. Then, they woke up, weeks or months later, with a new set of lungs.
This is the story of 20 near-death experiences and 20 lives saved by a first-of-its-kind procedure: a double-lung transplant for people who had survived severe COVID-19 but had irreparable lung damage.
"The COVID-19 double-lung transplant gives patients who were unprepared for death — and suddenly facing it — the opportunity to come back to life," says Northwestern Medicine Pulmonary Thoracic Surgeon Ankit Bharat, MD, who pioneered the procedure. "Without it, these patients may have never woken up after being put on ventilators because of how badly COVID-19 damaged their lungs."
Paths of Attack
When SARS-CoV-2, the virus that causes COVID-19, enters your system, it can latch onto the cells that line your respiratory tract. This includes your windpipe and lungs. Then, it starts to multiply at the expense of your healthy cells. Sensing danger, your immune system fights back, resulting in common symptoms such as a cough and fever.
"Your immune cells come together to fight COVID-19, which creates inflammation like a small wildfire," explains Dr. Bharat. "Depending on many factors, this wildfire can grow, causing massive inflammation and damage."
In the case of the 20 people who had double-lung transplants at Northwestern Memorial Hospital after having COVID-19, their immune systems could not put out the wildfire. SARS-CoV-2 spread through their respiratory systems, damaging their lungs.
These patients required the most advanced treatment possible in the Intensive Care Unit (ICU). They either received mechanical ventilation support or extracorporeal membrane oxygenation (ECMO) support from a machine that put oxygen into their blood with an external artificial lung.
When a patient with COVID-19 is supported by mechanical ventilation or an ECMO machine, the hope is that their infection will clear, their inflammation will go away and their lungs will start to heal themselves so they can breathe on their own. But healing did not happen for these 20 patients. They beat the virus, but their fight to survive was not over. The damage caused by COVID-19 takes two main forms: infection and scarring.
Inflammation can cause more inflammation. In patients with COVID-19, immune cells in the lungs can become too weak to fight off any intruder. That means other infections can easily take hold. If a bacterial infection occurs, the lungs become so weak that they cannot fight off infection, even with the help of the strongest antibiotics. The bacterial infection can spread into the bloodstream, causing sepsis and organ failure.
In June 2020, Chicago resident Mayra Ramirez became the first known person in the United States to receive a double-lung transplant after COVID-19 destroyed her lungs.
Mayra's lungs could not fight any infections. Pus clogged her lungs, preventing her from being able to breathe. When Mayra was in a medically induced coma and supported by a ventilator, she says all she remembers are dreams where she felt like she was drowning. During this time, her lungs were becoming "mushy with infection," according to Dr. Bharat.
Some patients can outlast the SARS-CoV-2 infection and begin to heal. However, healing can involve the creation of scar tissue, and stiff scar tissue is not ideal in the lungs. Lungs need to be soft with tiny holes that allow the transfer of oxygen into the bloodstream.
Roberto Rodriguez, the eighth person to receive a double-lung transplant following COVID-19, spent 130 days receiving ECMO support. This is the longest any patient has been known to be supported by an ECMO machine. His lungs became tough.
Infection or scarring can happen within the first few weeks of having COVID-19 or a few months into the illness.
Breakthrough in COVID-19 Care
A double-lung transplant was the only remaining treatment option for the 20 people at Northwestern Medicine who underwent this surgery.
"Mayra, the first transplant recipient, was young and otherwise healthy, with no options. I wanted to do everything I could for her," says Dr. Bharat. "There were a lot of challenges and tough decisions, but we knew this surgery was the right thing to do."
Mayra's surgery lasted 10 hours.
"They were 10 hours of uncertainty," says Dr. Bharat. "Managing that uncertainty and all the unexpected turns throughout the procedure required the team being as efficient and focused as possible."
From a medical standpoint, this procedure establishes for the first time that organ transplants can be effective after organ failure from infectious causes. Typically, organ transplant is considered because an organ is damaged by a chronic condition, such as emphysema, kidney failure or heart failure.
"Because this was a nontraditional use for organ transplant, we didn't know at first if the virus was going to come back after the transplant," says Dr. Bharat. "Now we know that transplant is a viable option for damage from infection, and we are considering transplant in patients with other infectious diseases like influenza."
Dr. Bharat has seen 100% success in the outcomes of all 20 patients who received lung transplants. Their road to recovery is slow. But because their disease was caused by a temporary infection, recovery is faster than for patients who need transplants for chronic lung conditions like cystic fibrosis or pulmonary fibrosis.
"Patients near death are getting back to living their normal lives," says Dr. Bharat.
Mayra is putting one foot in front of the other in physical therapy.
Rodrigo said his first words to his family since last Thanksgiving.
Leo Castillo of Washington, DC, the third patient to get a double-lung transplant at Northwestern Memorial Hospital after having COVID-19, is looking forward to getting back behind the wheel of his truck.
Texas resident James Teltschik, the ninth double-lung transplant recipient, looks forward to giving one of his signature bear hugs after his full recovery.
And while she's celebrating her recovery with a speaker and disco ball attached to her walker, 20th double-lung transplant recipient Amanda Longe-Asque looks forward to being able to sing again.
Leading the Quest for Better Medicine
Research on how viruses affect the body is usually done in laboratories over the course of years. With COVID-19, physician-scientists simply didn't have the time. They had to learn about how the SARS-CoV-2 virus attacks the lungs while caring for patients with the virus in the ICU.
Investigators worked together around the world and around the clock to publish information on COVID-19 and its effect on the body as they discovered it. Dr. Bharat paved the way for advanced COVID-19 care by pioneering the double-lung transplant following severe COVID-19. Now, under Dr. Bharat's guidance, institutions around the world are implementing this procedure to save even more lives.