Thursday, September 24, 2020

Double lung transplant, one of nation’s first, saves COVID-19 patient

Transplant News Sharing // News from Source www.houstonchronicle.com

When Memorial Hermann Hospital in The Woodlands allowed some of Francisco Medellin’s family to visit him from a window outside the intensive care unit last month, they all feared it might be the last time they’d see him.

Medellin, 69, contracted COVID-19 in June and despite interventions with the logical treatments, the disease ravaged his lungs, leaving him unable to breathe on his own. After a month of no progress, doctors told the family that there was little hope of him recovering.

“It was really sad,” said Maria Medellin, one of his daughters. “We thought the only thing we could do was pray. We hoped for a miracle.”

Medellin got a miracle of sorts, a double lung transplant, one of the first in the United States for the disease caused by the coronavirus. Typically a last-ditch effort for people with seemingly fatal, irreversible lung damage, such transplants are now on the radar for COVID-19 patients who are both acutely ill enough to need one and otherwise healthy enough to benefit from a transplant for a protracted period of time.

Medellin qualified on both counts. He got two new lungs at Memorial Hermann’s flagship hospital in the Texas Medical Center on Aug. 27, just a day after he’d gone on the donor transplant waiting list, and by last week he was in rehab. Doctors expect he’ll be ready for discharge next week.

He got the lungs quickly — the average wait time is three months — because his heart and lung function, oxygen requirements and other metrics were worse than most others on the list. The organ became available from a deceased patient at Memorial Hermann, one of the nation’s biggest trauma centers and donor hospitals.

A more common intervention?

Lung transplantation is expected to become a more common intervention for COVID-19 at U.S. transplant centers, though its use will be limited by the fact people hit hardest by the disease tend to have underlying health problems that make them ineligible for a donor organ. Still, Memorial Hermann doctors say they are now on the lookout for candidates and have identified a few.

“It’s a real sweet spot the doctors will need to identify,” said Chris Curran, vice president of organ operations at LifeGift, a not-for-profit organ procurement organization that recovers organs and tissue for individuals needing transplants in Houston and some other parts of Texas. “Might the patient recover without a lung transplant? Might the patient be too sick to benefit for long? Might any delay in decision-making render the transplant no longer viable? Doctors will have to straddle a tightrope.”

There have already been reports of the last scenario. Hospitals that got lung transplant procedures approved never got around to performing them because of disease complications that subsequently arose.

U.S. surgeons performed 2,700 lung transplants in 2019, most involving both organs. Though procurement rates have consistently been substantially lower than those for kidneys, livers and hearts, the number of lung transplants have increased every year in recent years as the procedure has become safer and survival rates better. Recipients, typically patients with pulmonary fibrosis or emphysema, now live an additional 10 to 12 years, twice the length of time they did in the 1990s.

The first lung transplantation for COVID-19 was reported in China Feb. 29, but it took until June for one to be performed in the United States, a 28-year-old Chicago woman who had spent six weeks on a ventilator before Northwestern Memorial Hospital doctors transplanted two lungs in her, a case that drew national attention. Northwestern doctors have performed two more lung transplants and the University of Florida did a fourth, on a Texas man in his 50s who was transported there. There have been no reports of others until Medellin’s last month.

“It’s been a little slow to roll out, but it’ll come,” said Dr. Soma Jyothula, medical director of the lung transplant program at Memorial Hermann and one of Medellin’s team of doctors. “There’s a learning curve. It’s a novel thing to do for a novel infection. Nobody knows how well it will work, not everyone’s aware it’s an option. These aren’t our usual patients, after all.”

Treatment plan

Like a lot of people who contract the virus, Medellin had no idea he was about to become a COVID-19 patient at all. He fought a cough and chills for nearly a week, then found himself so tired late on the morning of July 1. Family members noticed he’d turn blueish — a sign of oxygen deprivation. Alarmed, they brought him to the ER of Memorial Hermann’s hospital in Cypress. By the time he woke up, he’d been diagnosed with COVID-19.

Over the next six weeks — first at the Cypress, then at the Woodlands — Medellin got a variety of treatments: convalescent plasma, the therapy that transfers the antibodies of recovered patients; remdesivir, an antiviral that was the first treatment granted emergency approval for the disease; and dexamethasone, a steroid shown to help those severely ill with COVID-19. None appeared to provide any benefit.

Medellin never went on a ventilator, but doctors kept him stable with intakes of pure oxygen. Still, even after the virus was clear, his lungs never improved, and heavy scar tissue showed up in imaging. The team told the family the situation was dire.

But soon thereafter, doctors determined that a transplant might work for Medellin, who faithfully did early-morning calisthenics, never smoked or drank and coped with mild diabetes. He was transferred to the Texas Medical Center, where an assessment found he was indeed a good candidate, Memorial Hermann’s internal review board approved the plan and he went on the United Network for Organ Sharing wait list.

The surgery took about 12 hours, during which the left lung — all wet and heavy and inflamed, stuck to the chest wall — was the first removed. Things went without complication and Medellin needed less than 12 hours afterward on the breathing machine in the ICU, half what most patients need. Jyothula, also a professor of medicine at UTHealth, said that was a pleasant surprise that boded well for the recovery.

In less than two weeks, Medellin had been discharged to Memorial Hermann’s rehab unit. There, although weak, he walked the halls, attempted to climb stairs and finally got to be with family members, who choked up just talking about how close they’d come to losing him. They also expressed gratitude for the organs that saved him.

Asked if the roses smell sweeter and the food tastes better, Medellin smiled and said yes.

“I feel very happy for all the support and grateful to God to allow me to continue,” said Medellin, a retired construction worker, father of nine and grandfather of 32. “I’m looking forward to regaining my youth and energy and be able to work and enjoy my family. I’m happy to be able to live longer.”

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