Episode #2: Double the Miracle: How Double-Lung Transplants Saved COVID-19 Patients with Dr. Ankit Bharat

Dr. Albert Rizzo: Hello, I'm Dr. Albert Rizzo, Chief Medical Officer of the American Lung Association. Welcome to Lungcast.

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Dr. Albert Rizzo: This is the second episode of the monthly respiratory health series from the American Lung Association and HCP Live. In case you missed it, our debut episode last month featured HIV/AIDS research pioneer and world-renowned virologist Dr. David Ho, who led us through some of the clinical and public health challenges presented by COVID-19. If you missed it, be sure to tune in after listening to today's episode.

For now, let's introduce today's topic and guest. It is September 2020. Coronavirus has been a pandemic for six months, and there is still a distinct layer of uncertainty set forth by the virus and its ongoing global impact. Definitive resolutions—including vaccines, informed school and business reopening plans, and lifted social distancing mandates—remain hindered by the great unknowns of COVID-19. With its periodic surges and hot spots, the U.S. has finally achieved a drop in daily new cases and mortality, but true breakthroughs still await. Science, at its truest, is investigative, deliberate, and methodical, and as Dr. Ho recently told us, it's science that will deliver the solutions to COVID-19.

This past May, Dr. Ankit Bharat was an exception to that rule. In a moment of learning as you go, the Chief of Thoracic Surgery and Surgical Director of the Northwestern Medicine Lung Transplant Program led an unprecedented procedure: a double lung transplant of a young woman dying from COVID-19.

Dr. Albert Rizzo: Dr. Bharat joins us for a discussion on the COVID-19 discoveries made in his first and following patients, double lung transplants, how the prioritization of lung transplantation has and has not been influenced by the pandemic, and what his team's work meant for the immediate advancement of COVID-19 care in critically afflicted patients. We hope you enjoy.

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Dr. Albert Rizzo: So, I'm really pleased that you took the time today, Dr. Ankit Bharat, to talk to us at the American Lung Association. We know you're very busy, especially doing the surgeries that you've been doing, but I know our audience is very excited to start hearing about your transplant experience. Before we jump into that, I want to just get an opportunity to kind of fill me in on how you got to where you are, what made you decide to do surgery and transplant, and just fill us in on that a little bit if you could.

Dr. Ankit Bharat: Sure. I joined Northwestern about seven years ago. I came from St. Louis, Washington University, actually one of the meccas for lung transplant. Dr. Alec Patterson was one of the pioneers in the field; in fact, the first successful double lung transplant in the world involved one of my mentors there, and he was the head of cardiothoracic surgery. I was fortunate to be mentored by him.

I came to Northwestern about seven years ago as the Director of the future lung transplant program—we didn't have one at that point. We successfully launched that program, performed the first transplant in Independence Day 2014, and have been growing since. Our mission has been to take on not just straightforward situations and conditions but also more complex diseases that put patients at risk and may not be offered at other centers.

We routinely treat patients with all sorts of lung diseases, both standard and rare, from the local region, nationally, and internationally. When COVID started, we were involved with these patients right from the start because the virus predominantly affects the lungs. The thoracic surgery team and the pulmonary division worked closely to care for these patients, performing routine management as well as surgeries and procedures.

Ever since we saw the first patients, we anticipated that some would end up with completely damaged lungs despite the best medical treatment, stuck on ventilators with complications. We had toyed with the idea of exploring lung transplant as a treatment option for those patients who failed medical treatment and had no other option. We prepared our program, procedures, and policies to the best of our knowledge to treat these patients if needed.

Dr. Albert Rizzo: Transplanting a post-infectious person, especially someone with COVID-19, must have taken some thought on your team's part. How did you go about it? Were there any ethical issues that came up?

Dr. Ankit Bharat: Yes, it was a very complex decision. One of the paradigm changes this transplant brought was offering lung transplant for an infectious disease. We looked at it this way: we weren’t trying to treat the virus but the complication that resulted from it, leading to end-stage lung disease. Lung transplant is a treatment for end-stage lung disease, regardless of cause.

The big unknown was ensuring the host cleared the virus. If you transplant someone and immunosuppress them, could the virus come back? We had to go through rigorous testing to ensure these patients cleared the virus. We were fortunate to have cared for many of these patients and understood their natural course. We also implemented a warm autopsy program—unique regionally and nationally—which helped study virus clearance post-mortem.

Ethical concerns arose at the height of the pandemic: resources were strained, patients were coming in large numbers, and questions about reallocating resources for patients far into the disease process versus early-stage patients were challenging. There were also issues with lung supply; using a scarce organ on one patient while others wait posed difficult decisions.

Finally, there was risk to healthcare providers. Tests were evolving rapidly, and we needed to ensure safety when taking on such a high-risk task.

Dr. Albert Rizzo: Do you think your experience with this will help restructure lung allocation scores for donor lungs?

Dr. Ankit Bharat: I recognize the demand and supply gap, but it’s a gap that can be overcome. Only 15% of available lungs are currently utilized. With improved donor management, X Vivo lung perfusion programs, and expanded donor criteria, we can increase utilization. Patients in need, especially those severely affected by COVID, already receive high lung allocation scores. I hope COVID-19 will be recognized as a diagnosis code for transplant registration.

Dr. Albert Rizzo: You performed the first double lung transplant in COVID-19 in this country and a second one as well, correct?

Dr. Ankit Bharat: Correct. Two so far, and we are evaluating several others flown to Northwestern. These patients are weeks and months into COVID, ECMO-dependent, with multiple complications but otherwise young and healthy, with no other option.

Dr. Albert Rizzo: Were there any particular moments when you first met these patients that stood out?

Dr. Ankit Bharat: The first patient we intended to transplant in April had multi-organ failure and unfortunately expired. The first successful transplant patient was 28, very sick, and her family was deeply invested in her care. The second patient, also severely ill, was transplanted within three days of listing and is doing well.

Dr. Albert Rizzo: These transplants sound very different anatomically and physiologically from COPD or pulmonary fibrosis transplants.

Dr. Ankit Bharat: Yes. COVID patients are often critically deconditioned, ICU-bound, sedated, immobilized, with multiple complications. Double lung transplant is already a complex procedure, and COVID-affected lungs destroy normal anatomic planes, making surgery highly challenging. Post-op recovery is intensive, with immunologic challenges due to prior transfusions, ECMO, and convalescent plasma.

Dr. Albert Rizzo: ECMO is increasingly used as a bridge to transplant. Does that increase complications?

Dr. Ankit Bharat: ECMO allows patients to reach transplant but does not itself cause complications. Patients requiring ECMO are simply sicker initially, so their outcomes reflect their baseline condition, not ECMO. With proper selection, outcomes are excellent.

Dr. Albert Rizzo: How do you see the future of transplant centers and surgeons, medically and in terms of resources?

Dr. Ankit Bharat: Lung transplant is growing, but it’s resource-intensive, requiring large teams and support staff. Post-op outcomes and intra-op survival have dramatically improved. Indications have broadened beyond pulmonary fibrosis, emphysema, and cystic fibrosis to include sarcoidosis, pulmonary hypertension, connective tissue disorders, and now COVID-19. With proper support, transplant programs can have a major impact.

Dr. Albert Rizzo: What about lung volume reduction procedures as a bridge to transplant?

Dr. Ankit Bharat: Lung volume reduction surgeries, including robotic approaches, have improved outcomes and shortened recovery. While helpful for some emphysema patients, these procedures don’t significantly alter transplant numbers. Emphysema patients get lower lung allocation scores due to lower waitlist mortality, which affects transplant frequency.

Dr. Albert Rizzo: Has post-op management improved with newer immunosuppressive drugs?

Dr. Ankit Bharat: Yes, but lung transplant immunosuppression still relies on conventional drugs like cyclosporine and steroids. We are exploring novel agents in our NIH-funded research program to improve long-term survival.

Dr. Albert Rizzo: You previously conducted research on carbon dioxide effects on the airway for the American Lung Association. Can you summarize that?

Dr. Ankit Bharat: Early in my career, ALA funding helped me study delayed lung wound healing post-lung cancer surgery. We found increased carbon dioxide impairs healing via cellular signaling, delaying closure of lung tissue defects. This research led to innovations like a new chest drainage system at Northwestern and advanced our understanding of lung biology.

Dr. Albert Rizzo: Thank you for sharing that mission moment. Anything else about transplant challenges or innovation?

Dr. Ankit Bharat: Lung biology remains under-recognized despite its global impact on mortality. ARDS, whether from COVID or influenza, is prevalent. Innovation in transplant, lung injury understanding, and repair is crucial.

Dr. Albert Rizzo: Can you comment on the rapid collaboration during the pandemic and how it affected your work?

Dr. Ankit Bharat: Collaboration has been unprecedented. We shared insights regionally, nationally, and internationally, learning from and assisting others. Bronchoscopies and biopsies helped us understand pathology, and warm autopsy programs allowed study at the single-cell level. Transplant is now recognized as a potential option for patients who fail medical therapy.

Dr. Albert Rizzo: Any final updates on research?

Dr. Ankit Bharat: We have two papers in the final stages, one for the New England Journal of Medicine and another for Nature, exploring unique pathways in pandemic lung biology.

Dr. Albert Rizzo: Thank you for your time, Dr. Bharat.

Dr. Ankit Bharat: Thank you.

Dr. Albert Rizzo: Thank you again to Dr. Bharat for his insight into this monumental breakthrough in lung transplantation. His and his team's work provide a foundation for more promising care for patients severely afflicted with COVID-19. Thanks to our listeners for tuning in to the second episode of Lungcast.

We’re glad to have kicked off this new project with world-leading experts discussing their roles in the greatest public health crisis of our time. Stay tuned for next month’s guest, possibly the most trusted man in medicine today, sharing thoughts on the pandemic.

If you can't breathe, nothing else matters—just take it one breath at a time.