In conversation with Dr. Kumud Kumar Dhital Sr. Consultant Cardiothoracic Surgeon Program and Surgical Director for Heart & Lung Transplantation and MCS Yashoda Hospitals
Whilst most units are now seeing a slow return of routine activity, the necessary catch-up to serve the backlog of procedures will require considerable planning and injection of resources, including upskilling of staff who have lost out on their normal education and vocational training.
COVID Impact on Heart and Lung Transplants and Cardiothoracic Surgeries
Cardiac surgery, complex thoracic surgery and all of Heart and Lung transplantation procedures require post-operative management in Intensive Care Units (ICU). The unanticipated pressure of thousands of COVID-positive patients requiring advanced care in the ICU setting, led to a significant number of cardiothoracic surgery (CTS) services to suspend everything but the emergency and urgent cases. CTS services that were able to carry on providing a service have seen a reduction up to 90% of that pre-COVID-19. Due to the shortage of ICU beds, decreased organ donation rates observed globally during the pandemic, and the fear of vulnerable transplant recipients with end-stage heart or lung failure from catching the SARS-CoV-2 infection, many transplant units also suspended activity or continued with considerably reduced activity.
The postponement of routine and non-urgent CTS cases has resulted in a backlog of surgical cases with the unfortunate consequence of some dying whilst waiting or experiencing a deterioration of their clinical condition with worse mortality and morbidity risk when they are eventually admitted. Whilst most units are now seeing a slow return of routine activity, the necessary catch-up to serve the backlog of procedures will require considerable planning and injection of resources, including upskilling of staff who have lost out on their normal education and vocational training.
Long COVID and likely impact on Heart and Lung Transplantation
Long COVID or Chronic COVID Syndrome (CCS) refers to the medium to long-term persistence of medical symptoms beyond 12 weeks following an initial COVID-19 infection and is distinct from the earlier post-acute COVID stage of 4-12 weeks from the initial insult. In addition some of the usual COVID symptoms ranging from cough, fatigue, loss of smell or taste, shortness of breath, muscle weakness, joint aches and headaches, Long COVID is also characterized by: post-ICU syndrome; post-viral fatigue syndrome; chronic damage to the lungs and heart; as well as neurological and psychological morbidity. Patients with unresolving and or worsening lung or heart damage may need to be reviewed for transplantation.
We have yet to fully understand the natural history of post-SARS-CoV-2 infection, but the current and increasing burden of Long COVID with physical and mental manifestations will require adequately funded and resourced, integrated and holistic programs for long-term surveillance and rehabilitation.
Current outcomes of Lung Transplantation
Lung transplantation is now an accepted and evidence-based best therapy for selected patients with end-stage lung disease for which there are no further medical or non-transplant surgical options available. Suitable patients should have more than 50% chance of dying within the next two years without intervention and an expected survival of more than 80% following the procedure. About 5000 lung transplants are performed annually world-wide with the majority being double lung as opposed to single lung transplants.
The lung transplant Registry at the International Society of Heart and Lung Transplantation (ISHLT) shows 1, 5, 10 and 15 year post-transplant survival of 85%, 61%, 42% and 28% respectively. Several high volume centres have reported even better survival rates. This is despite there being older recipients with more medical co-morbidities, more urgent procedures in very sick patients being bridged with artificial lung support in the ICU and having to use more marginal organs due to the continued shortage of donors.
Survivorship in Organ Transplantation
The success of organ transplantation is neither defined by the safe completion of the surgical procedure nor by successful discharge home from the hospital admission. The success of transplant procedures is defined by survival beyond the time at which the recipient would have otherwise been expected to die without the intervention. However, the continuously improving outcomes of organ transplantation require us to aim even higher, by attention to long-term survivorship which therefore results from more than good surgical technique and expert post-transplant care. The myriad of physical and psycho-social issues, the need for disciplined compliance with life-long medications, anxiety over the reality of side effects of immunosuppressive drugs, the requirement for life-long surveillance of graft function and monitoring of other medical conditions, all compound to determine the window of survival post-transplantation.
Early referral for transplant evaluation permitting sufficient time for building a trusting relationship between recipients and their families with the transplant team is crucial. Without this rapport, there is a decline in compliance and general adherence with post-transplant medication regimes and surveillance protocols. Many patients continue to require psychological support into the medium to long-term post transplantation. damage from end-stage chronic rejection or other terminal condition, will ensure a better quality of life and acceptance of their medical condition.
Current scenario of organ donation during the pandemic and heart and lung transplants in India.
At the height of the pandemic, many transplant units had a self-imposed or mandated requirement to suspend transplant activity. Vital intensive care beds but also other infrastructural and manpower resources were necessarily diverted to the care of sick COVID-positive patients. The decline in the rate of organ donation during the pandemic and the appropriate concern of exposing vulnerable post-transplant immunocompromised patients to potentially devastating SARS-CoV-2 infection were further reasons for the significant decline in transplant activity over this time.
The larger volume transplant centres were faced with many patients with unresolving post-COVID lung damage, some of whom required bridging with an artificial lung support in the form of extra-corporeal membrane oxygenation (ECMO). These units were able to rise to the challenge and successfully transplant a number of these patients. Currently, organ donation rates are starting to pick up with the expectation that many medically end-palliated patients will finally be able to get their transplants during the course of this new year.