US Covid-19 patient undergoes rare double-lung transplant

CHICAGO (NYTIMES) – The last thing that Mayra Ramirez remembers from the emergency room at Northwestern Memorial Hospital in Chicago is calling her family to say she had Covid-19, was about to be put on a ventilator and needed her mother to make medical decisions for her.

Ramirez, 28, did not wake up for more than six weeks. And then she learned that on June 5, she had become the first Covid-19 patient in the United States to receive a double-lung transplant.

Mayra Ramirez, 28, after her surgery at Northwestern Memorial Hospital in Chicago.
Mayra Ramirez, 28, after her surgery at Northwestern Memorial Hospital in Chicago.PHOTO: NYTIMES

Last Wednesday (July 29), she went home from the hospital.

Ramirez is one of a small but growing number of patients whose lungs have been destroyed by the coronavirus and whose only hope of survival is a lung transplant.

“I’m pretty sure that if I had been at another centre, they would have just ended care and let me die,” she said in an interview on Wednesday.

The surgery is considered a desperate measure reserved for people with fatal, irreversible lung damage. Doctors do not want to remove a person’s lungs if there is any chance they will heal. Overall, only about 2,700 lung transplants were performed in the United States last year.

Patients must be sick enough to need a transplant and yet also strong enough to survive the operation, recover and get back on their feet. With a new disease like Covid-19, doctors are still learning how to strike that balance.

“It’s such a paradigm change,” said Ramirez’s surgeon, Dr. Ankit Bharat. “Lung transplant has not been considered a treatment option for an infectious disease, so people need to get a little bit more of a comfort level with it.”

On July 5, he performed a similar operation on a second Covid-19 patient, Brian Kuhns, 62, from Lake Zurich, Illinois.

Kuhns spent 100 days on life-support machines before receiving the transplant. Before becoming ill, he had thought Covid-19 was a hoax, his wife, Nancy Kuhns, said in a statement issued by the hospital.

Brian Kuhns said, “If my story can teach you one thing, it’s that Covid-19 isn’t a joke.”

Two more patients at Northwestern are awaiting transplants – one from Chicago and one from Washington, DC – said Bharat, who is chief of thoracic surgery and surgical director of the lung transplant program.

A patient is to be flown in from Seattle next week, and the Northwestern team is consulting on still another case with a medical group in Washington. Other transplant centers are considering similar surgeries, Bharat said.

Last Friday, a Covid-19 patient transferred from another state underwent a double-lung transplant at the University of Florida Health Shands Hospital in Gainesville, Dr Tiago Machuca said.

While other centres have also sought to refer cases, most of the patients had other serious medical problems that ruled them out, he said.

In some cases, Bharat said, hospitals appeared to have waited too long to recommend a transplant. One patient being referred to his centre seemed like a good candidate but then had major bleeding into the lungs as well as kidney failure, and the surgery was no longer feasible.

“I think people need to recognise this option earlier and just start at least talking about it before it gets to that point,” Bharat said.

Because the extensive lung damage in Covid-19 patients makes transplant surgery especially difficult, most patients would be referred to major transplant centers that are best equipped to perform the risky operations and provide the intensive aftercare that patients need, the surgeons said. Brian Kuhns was transferred to Northwestern from another health system.

Before she became ill, Ramirez, a paralegal for a law firm specialising in immigration, was working from home and having her groceries delivered. She was in good health but had an autoimmune condition, neuromyelitis optica, and took medication that suppressed her immune system and might have made her more vulnerable to the coronavirus infection.

She was ill for about two weeks and consulted with a Covid-19 hotline about her symptoms. At one point, she headed to the hospital but then turned back without going in. She dreaded the idea of being admitted and told herself she would recover.

But April 26, her temperature reached 105 degrees Fahrenheit, and she was so weak that she fell when she tried to walk. A friend drove her to the hospital. When doctors told her that she needed a ventilator, she had no idea what they meant. She thought it meant some kind of fan, like the word in Spanish.

“I thought I’d just be there for a couple of days, max, and get back to my normal life,” she said.

But she spent six weeks on the ventilator and also needed a machine to provide oxygen directly into her bloodstream.

The disease was relentless. Bacterial infections set in, scarring her lungs and eating holes in them. The lung damage caused circulatory problems that began to take a toll on her liver and heart.

The doctors told her family in North Carolina that it might be time to come to Chicago to say goodbye, and her mother and two sisters made the trip.

But Ramirez held on, cleared the coronavirus from her body and was placed on the transplant list. Two days later, on June 5, she underwent a 10-hour operation.

She woke scarred, bruised, desperately thirsty and unable to speak, “with all these tubes coming out of me, and I just couldn’t recognise my own body.” The nurses asked if she knew the date. She guessed early May. It was the middle of June.

She was not told she’d had a lung transplant until several days after she woke up.

“I couldn’t process it,” she said. “I was just struggling to breathe, and I was thirsty. It wasn’t until weeks later that I could be grateful, and think there was a family out there who had lost someone.”

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