Woman Lives Six Days Without Lungs

Woman Lives Six Days Without Lungs

By: Aadil Ali
An interview with Dr. Marcelo Cypel,
Assistant Professor of Surgery, University of Toronto. Canada Research Chair in Lung Transplantation (Tier 2).
Surgical Director of UHN’s Extracorporeal Life Support Program

Recently, the stellar Toronto transplant team made media headlines after performing an innovative life-saving procedure. For the first time in history, the team removed a patient’s lungs—and kept her alive for six days.

Patient M.B., a mother from Burlington, was born with cystic fibrosis. Cystic fibrosis is a genetic disease that produces a variety of symptoms; such as, the production of thick mucus that can block pancreatic ducts, intestines, and notably—the bronchi of the lungs. Blockage of the lungs is usually followed with episodes of respiratory infections, leading to an accumulation of bacteria within the lungs. The treatment for end-stage cystic fibrosis is lung transplantation, in conjunction with high-dose antibiotics to manage the bacterial infection. Unfortunately, bacteria that accumulate in the lungs can become resistant to antibiotics. If resistant bacteria enter systemic circulation, they may spread to different areas of the body, resulting in a large-scale inflammatory response. This phenomenon, known as septic shock, can lead to dangerously low blood pressure and metabolic abnormalities.

While M.B. awaited donor lungs, sepsis began to take over her body. Her oxygen levels dipped so low that conventional ventilation was no longer an effective option. M.B. was receiving maximum doses of powerful antibiotics and medications to regulate her falling blood pressure. Without any other options, the Toronto team boldly asked—what if we removed the source of the sepsis?

Dr. Marcelo Cypel, surgical director of UHN’s Extracorporeal Life Support (ECLS) Program, describes, “We felt her only potential chance of surviving was to remove the source of infection, which meant removing both of her lungs. If you do that, ideally you want to put the new lungs in right away. But we didn’t have that available to us at the moment. Another thing is that you do not want to perform a transplant when the patient is in sepsis, because this also is very risky. As a result, even if we had lungs at the time, the transplant still would have been too risky, as her chance of survival would have been very low.”

At this point, Dr. Cypel sought advice from his colleagues: UHN’s Surgeon-in-Chief and the Director of the Toronto Lung Transplant Program, Dr. Shaf Keshavjee; and Head of Thoracic Surgery at UHN, Dr. Tom Waddell. After careful consideration, the team decided that this pioneering procedure was M.B.’s only option. Dr. Keshavjee, Dr. Waddell, and Dr. Cypel would perform the surgery together.

Their procedure utilized two extracorporeal life support systems. Specifically, the surgeons used a venous-arterial (VA) extracorporeal membrane oxygenation (ECMO) circuit paired with an artificial lung device known as the Novalung. Essentially, the Novalung served to remove carbon dioxide from M.B.’s blood, while providing a fresh supply of oxygen; the ECMO circuit helped her heart pump blood throughout her body.

“The procedure took about five to six hours, and then the transplant took another five to six hours the following week. It usually takes a bit longer to do the transplant, but half our job was already done since M.B.’s lung were already removed,” explains Dr. Cypel.

Six days after the initial procedure, the transplant team learned that a set of donor lungs were available for M.B. Effectively, this procedure served as a bridge to transplantation for M.B., and can potentially be used to save the lives of other cystic fibrosis patients who are on a waiting list to receive an organ. Interestingly, this life support configuration could have potentially allowed M.B. to survive without her lungs for a longer period of time. This could be important for patients who may have weeks of waiting before matching to a set of donor lungs. Although M.B.’s prognosis is still unknown, she is currently in a state of great recovery.

Dr. Cypel says he believes that this procedure will become common in coming years. “This was not the first patient [who] needed this procedure. We had many patients in the past that we just accepted had to die. This patient was different because it reached a point when this idea was mature enough between the team. We felt that now was the time to do it. Another thing was that we had the family’s support to do it… I think this will be a game-changer, not only for us, but for other hospitals around the world. Everyone is faced with these issues, especially patients with Cystic Fibrosis.”

For interested readers, a detailed description of the surgical procedure is outlined in a recent publication entitled “Bilateral pneumonectomy to treat uncontrolled sepsis in a patient awaiting lung transplantation,” published in the Journal of Thoracic and Cardiovascular Surgery.3

References

  1. Nakajima D, Liu M, Ohsumi A, et al. Lung lavage and surfactant replacement during ex vivo lung perfusion for treatment of gastric acid aspiration–induced donor lung injury. J Heart Lung Transplant. 2016;010.
  2. Machuca T, Cypel M, Bonato R, et al. Safety and efficacy of ex vivo donor lung adenoviral IL-10 gene therapy in a large animal lung transplant survival model. Hum Gene Ther. 2016; 10.1089.
  3. Cypel, Marcelo, Thomas Waddell, Lianne G. Singer, Lorenzo del Sorbo, Eddy Fan, Matthew Binnie, Niall D. Ferguson, and Shaf Keshavjee. “Bilateral pneumonectomy to treat uncontrolled sepsis in a patient awaiting lung transplantation. J Thorac and Cardiovasc Surg.2016: doi: 10.1016/j.jtcvs.2016.11.031.

Dear Readers,

A few days after our Spring issue went to press, we were saddened to learn that patient M.B., the subject of the article, “Woman Lives Six Days Without Lungs: An Interview with Dr. Marcelo Cypel,” had passed away. We would like to commend M.B. and her team of surgeons and caregivers for their incredible bravery. Those who courageously explore and push the boundaries of science are truly heroes in the field of medicine. On behalf of the IMS Magazine, we express our sincere condolences to the family and friends of M.B. – we are honoured to play a small role in sharing her story.

Sincerely,

Sarah Peters and Petri Takkala, Editors-in-Chief