• Ankit Bharat, Tiago N Machuca, Melissa Querrey, Chitaru Kurihara, Rafael Garza-Castillon, Samuel Kim, Adwaiy Manerikar, Andres Pelaez, Mauricio Pipkin, Abbas Shahmohammadi, Mindaugas Rackauskas, Suresh Rao Kg, K R Balakrishnan, Apar Jindal, Lara Schaheen, Samad Hashimi, Bhuvin Buddhdev, Ashwini Arjuna, Lorenzo Rosso, Alessandro Palleschi, Christian Lang, Peter Jaksch, BudingerG R ScottGRSDivision of Thoracic Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Northw, Mario Nosotti, and Konrad Hoetzenecker.
• Division of Thoracic Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, IL, USA. Electronic address: Ankit.Bharat@nm.org.
• Lancet Respir Med. 2021 May 1; 9 (5): 487-497.

BackgroundLung transplantation is a life-saving treatment for patients with end-stage lung disease; however, it is infrequently considered for patients with acute respiratory distress syndrome (ARDS) attributable to infectious causes. We aimed to describe the course of disease and early post-transplantation outcomes in critically ill patients with COVID-19 who failed to show lung recovery despite optimal medical management and were deemed to be at imminent risk of dying due to pulmonary complications.MethodsWe established a multi-institutional case series that included the first consecutive transplants for severe COVID-19-associated ARDS known to us in the USA, Italy, Austria, and India. De-identified data from participating centres-including information relating to patient demographics and pre-COVID-19 characteristics, pretransplantation disease course, perioperative challenges, pathology of explanted lungs, and post-transplantation outcomes-were collected by Northwestern University (Chicago, IL, USA) and analysed.FindingsBetween May 1 and Sept 30, 2020, 12 patients with COVID-19-associated ARDS underwent bilateral lung transplantation at six high-volume transplant centres in the USA (eight recipients at three centres), Italy (two recipients at one centre), Austria (one recipient), and India (one recipient). The median age of recipients was 48 years (IQR 41-51); three of the 12 patients were female. Chest imaging before transplantation showed severe lung damage that did not improve despite prolonged mechanical ventilation and extracorporeal membrane oxygenation. The lung transplant procedure was technically challenging, with severe pleural adhesions, hilar lymphadenopathy, and increased intraoperative transfusion requirements. Pathology of the explanted lungs showed extensive, ongoing acute lung injury with features of lung fibrosis. There was no recurrence of SARS-CoV-2 in the allografts. All patients with COVID-19 could be weaned off extracorporeal support and showed short-term survival similar to that of transplant recipients without COVID-19.InterpretationThe findings from our report show that lung transplantation is the only option for survival in some patients with severe, unresolving COVID-19-associated ARDS, and that the procedure can be done successfully, with good early post-transplantation outcomes, in carefully selected patients.FundingNational Institutes of Health. VIDEO ABSTRACT.Copyright © 2021 Elsevier Ltd. All rights reserved.

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