The UCLA Lung Transplant Program continues to be one of the nation’s busiest — having performed 120 lung transplants in 2020, more than in any prior year in the program’s history. Beyond the volume, the program has results that are among the nation’s best, despite being a referral center for some of the most difficult cases — among them, patients who have been turned away at other lung-transplant centers. “We are able to bring in higher-risk patients because of the combination of having a volume that supports risks and the experience that comes with that volume, which includes dealing with very challenging medical situations and complex issues, such as patients with a heart problem who need a lung transplant or a systemic disease that’s damaged their lungs,” says David Sayah, MD, PhD, the program’s medical director.
One of the reasons some of the most seriously ill patients are better off awaiting a lung transplant at UCLA is the program’s leadership in the use of extracorporeal membrane oxygenation (ECMO), a cardiopulmonary bypass machine that pumps oxygenated blood into the veins and arteries, allowing the lungs and heart a chance to heal. At UCLA, ECMO is employed to provide a bridge to transplant for patients who could benefit from one but become decompensated and require the intensive care treatment to keep their window to a transplant open.
After doing the procedure, a team of ICU physicians provides around-the-clock care until a transplant can be performed. “ECMO gives us the ability to stabilize patients who would otherwise not be candidates for transplantation because their lungs aren’t working, so that they can be bridged safely to lung transplantation,” says Abbas Ardehali, MD, director of the UCLA Lung Transplant Program. He notes that UCLA has one of the broadest experiences in the nation with ECMO patients going into lung transplantation, with more than 80% eventually receiving lung transplantation and nearly 100% able to return home from the hospital after the transplant.
“The transplant operation is much more complex because these patients are sicker and on blood thinners, but despite these adversities, they have done well, making ECMO a useful adjunct for patients who have no other options,” Dr. Ardehali says. “This is a resource- and talent-rich undertaking that’s only possible at an institution like UCLA.” “It’s much better when patients are referred early, before they need bridging, so that we can try to avoid ECMO,” Dr. Sayah notes. “But sometimes patients decompensate so quickly that it can’t be avoided, or the wait time is longer than what we anticipated, the standard ways we get patients oxygen in the hospital aren’t enough and they need additional support. In such cases, ECMO gives them a chance to receive that transplant, leave the hospital and return to their lives. It fits with our overall commitment that when a patient needs a transplant, we’re going to do whatever we can within our capabilities, which are considerable, to get them to that point.”
Drs. Sayah and Ardehali point out that the use of ECMO as a bridge to transplantation is just one of many examples of the UCLA program’s commitment to taking on high-risk cases. “As a state institution, we should be, and are, the last resort for patients without options,” Dr. Ardehali says. “As such, we have expanded our indications.” He notes that, for example, patients with heart conditions and those with mixed connective tissue disease, as well as patients considered too old by other centers, have been accepted for lung transplantation by the UCLA program, with good results.
Overall, Dr. Ardehali says, improvements in the surgery, as well as in perioperative and postoperative care, have meant that patients who would have had no chance at survival even 15 years ago are now able to get transplanted and go home to lead productive lives. One of the major challenges facing the field continues to be that lungs are more prone to rejection than other transplanted organs — most likely because they are exposed to air, activating the immune system. UCLA and Duke University will soon launch a clinical trial of a new immune-suppression strategy designed to address this concern. Because of the rejection issue,median survival after a lung transplant is approximately six years. “That’s shorter than for other solid organs, but these are patients who would otherwise have very short life expectancies,” Dr. Sayah says. “And maybe even more important is the fact that their quality of life without a transplant is extremely poor. With a transplant, it’s almost like watching someone be reborn. Seeing that and hearing from those patients is one of the things that keeps us doing this work.”