Innovations in Managing Lung Failure

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. This podcast will explore disease prevention, testing, medical and surgical treatments, new innovations and more. Enjoy.

Kenneth McCurry, MD:

Good day. Happy to have you join us here today. My name is Ken McCurry. We're here to talk about lung failure management at the Cleveland Clinic, what we do, how we do it and how that interfaces with our lung transplant program. By way of introduction, again, I'm Ken McCurry. I'm a cardiothoracic surgeon here at the Cleveland Clinic and the Surgical Director of the Lung and Heart-Lung Transplant Program. I’m Surgical Director of the Respiratory ECMO Program and Ex Vivo Lung Transplant Program as well. I'm happily joined today by Marie Budev.

Marie Budev, DO:

Hello and welcome everyone. We're really excited to have you join us today to talk about lung failure and lung transplantation here at the Cleveland Clinic. Again, my name is Marie Budev. I'm the Medical Director of the Lung and Heart-Lung Transplant Program here at the Cleveland Clinic, and I get to work closely with Dr. McCurry in this area.

We'll go ahead and get started. Ken, the Cleveland Clinic is well known for its management of end-stage lung disease and lung failure, and it's a multidisciplinary approach that we've always used here. Can you comment a little bit more about that, and what that involves and entails?

Kenneth McCurry, MD:

Yeah, thanks, Marie. I think we really pride ourselves here at Cleveland Clinic in working in teams and that's our approach to pretty much everything that we do. We're quite collegial and engaged. We have a dedicated group of surgeons and pulmonologists. Marie Budev, as Marie articulated, is the medical director of the lung program, so she helps lead a group of pulmonologists who are dedicated purely to lung transplantation. In addition to Marie, we also have a group of other pulmonologists who are also quite dedicated to lung failure in general, particularly in the ICU as it relates to ECMO treatment or ECMO support of respiratory failure, as I think we'll talk about a little bit later today.

Then we certainly have a very dedicated group of intensivists both in our cardiothoracic ICU, as well as in our MICU. How we engage on a daily basis is really seamless. We commonly make joint rounds routinely so that we bring the expertise of all these people to bear in terms of treating patients with end-stage lung disease to try to optimize their outcomes.

Marie Budev, DO:

I can add to that. For our end-stage lung disease patients, especially those going on to need transplantation, it truly is a team of teams approach. This starts from the beginning when we first start evaluating patients that have end-stage lung disease for lung transplant. It is multiple teams that are involved, but communication is seamless, and that's something that's very important to know right now in this state of healthcare. We talk to each other, most of all, we talk to you and we keep you and your family updated on all events as part of the evaluation and during the perioperative period.

The surgeons, the pulmonologist, the ICU team, all the other consultants, the infectious disease team, the nutritionist, the physical therapist, we all talk on a daily basis, if not a couple of times a day. Then we sit down and talk to you as well as your family. Communication is seamless, and it continues on after transplant and after you leave the hospital. It never stops. This is a core value of our program, and we continue to follow this very closely.

Kenneth McCurry, MD:

That's great, Marie. I think it truly is a very engaging environment, both from a collegial, professional standpoint in terms of trying to optimize care of the patients, as well as, as you very well articulated, our dedication to talking to patients and their families in a joint fashion as to how to manage their problem.

Marie Budev, DO:

There've been some advances in lung transplant in the last few years and the Cleveland Clinic has been at the forefront and the cutting edge of these advances. Ken, can you comment on EVLP (ex vivo lung perfusion), ECMO bridging and a few other advances? And then we can talk a little bit more about patient selection criteria and how the Cleveland Clinic is, again, at the cutting edge of this.

Kenneth McCurry, MD:

So I think as you state and well know, our lung transplant program here at the Cleveland Clinic is one of the largest, if not the largest lung transplant program in the country. Our sole purpose and our guiding light is to offer this therapy to as many patients as we can, to hopefully help them live a longer and better life. We generally do about 130-150 lung transplants a year. That allows us the opportunity to do some new and unique things to try to optimize their outcome, as well as, as I stated, to try to offer this therapy to more people.

One of the things that we've been instrumental in helping to develop over the last eight or nine years, as Marie alluded to, is ex vivo lung perfusion. This is a technique where we take lungs that are marginal or we feel are not transplantable, commonly declined by multiple other lung transplant programs in the United States, we bring them back to our center, and we put them on a machine where we can perfuse solutions through them over a period of a few hours, and then evaluate those lungs. There are techniques that we have and things that we do that we think help rehabilitate those lungs, potentially to make them better and to make them transplantable, and then we can offer those lungs to our recipients.

In general, we've been able to transplant an additional 30 to 35 or 40 patients a year utilizing this strategy, with outcomes that are as good or better than lungs that we take straight to transplant. This has been a real focus of our institution over the last eight or nine years and something that I think our people, our program do quite well. We think there's still more opportunity to offer more lungs to patients utilizing this sort of strategy.

It's still a bit unfortunate that globally in the United States, as you well know, only about 20-22% of lungs from donors are actually transplanted. We think there's an opportunity, in many more patients waiting to get a lung, we really think there's an opportunity to potentially double the number of lung transplants that we're doing in the United States over the next five years or so.

Marie Budev, DO:

Ken, you made a great point that there are more donors out there that are not being utilized. We continue to have thousands of patients die on the waiting list waiting for organs. What else are we doing in terms of selection of donors that's unique at the Cleveland Clinic?

Kenneth McCurry, MD:

Our approach, and I think this is part of our culture and our program here, is that our default answer to an organ is “yes,” and we have to find reasons to say no. I think that's really our guiding principle. This may not be true across the country. Sometimes transplant donor offers come at inopportune times, when surgeons and medical pulmonologists and other people are busy doing other things. Sometimes if there's some question of marginality or something else like that, it can be a common reason why organs are declined.

So, we start from the premise that an organ is suitable for transplant, and it really has to prove to us that it's not, including the use of EVLP. We're very aggressive with going out to look at donor organs. We do things both in the donor OR and ultimately, if we have to, on EVLP to try to make those organs better. That allows us to utilize a lot of organs that otherwise would've gone to waste and to hopefully save lives in doing so.

Marie Budev, DO:

I think Ken made a great point. For you as a patient, it's about saving your life. If you need an organ, this institution, the Cleveland Clinic is dedicated. You're here to get an organ and that's what our aim is, whether it's using EVLP or whether it's using aggressive donor management practices. Things that change in the environment of transplantation such as the allocation system, this has actually benefited us at the Cleveland Clinic. We have always gone out for organs all over the country. We continue to do that, and we do that every opportunity we get.

As Ken said, an organ has to really show us it's not a good organ to transplant. We are very aggressive in the management of these organs, making sure that they work well and that they will serve our patients. again, the take-home message for all of you as patients and patient families and caregivers, if you come to the Cleveland Clinic, we are here to transplant you. When you are on our list, our aim is to get you transplanted.

Kenneth McCurry, MD:

Maybe if I could, Marie, I could ask you how our program goes about the evaluation process and how we've extended the criteria to complex patients and patients with other difficulties for transplantation that perhaps other programs won't consider.

Marie Budev, DO:

Yeah, thanks, Ken. That's a great question. Over the last decade or more, the Cleveland Clinic has approached a patient the same way we approach a donor, actually. You have to show us you are not going to be an appropriate candidate. We are taking highly complex patients with multiple different comorbidities. This could be cardiac comorbidities, this could be issues with their GI tract, such as reflux. Patients that may be turned down at other institutions for other medical reasons, we feel comfortable handling and transplanting. About 30% of our referrals are from other institutions, and about 30% of our patients that we do transplant off our list have been referred from another hospital where they've been turned down.

So, we encourage you to talk as a patient to your caregivers, to your doctors, your primary pulmonologist to have you referred here early. Early referral is absolutely essential. Again, if you have other medical problems such as cardiac disease, may need a bypass, a valve, or you may be of older age or have other comorbidities such as scleroderma and other diseases, reach out to us.

The one thing I do want to highlight, if there is any question about your candidacy, even before you are referred, just reach out to us. If you go to the Cleveland Clinic webpage and put in “lung transplant,” it'll take you directly to our website where there is a phone number listed where you can reach out to us and ask us any questions. You will get a phone call from either myself, one of my pulmonology colleagues, or from one of our coordinators to help you understand and navigate through the whole testing process and through the referral process as well. There's a lot of help out there, just reach out to us.

Kenneth McCurry, MD:

Yeah, that's great, Marie. I think as you well articulate, we're very experienced. We have a wealth of experience on the surgical side and certainly a wealth of experience and a great team on the medical side. Our ICUs do an outstanding job as well. That really allows us to take on the complexity of some patients who are declined at other centers.

So, Marie, we talked a little bit about EVLP and a lot of the research we have going on the pre-transplant side and donor utilization side. Maybe you could talk to us a little bit about the research that's going on the post-transplant side.

Marie Budev, DO:

Thanks, Ken. We're doing a lot of work on the medical lung transplant side of things. Still, there's so much we don't know in lung transplantation. We've been fortunate enough at the Cleveland Clinic, we have a very strong research team. Not only just looking at outcomes, we all serve on major societies as well as on UNOS (United Network for Organ Sharing) and OPTN (Organ Procurement and Transplantation Network), but we also have clinical trials that go on. One of the advantages of coming to an institution like the Cleveland Clinic, these clinical trials offer you the opportunity to be enrolled both pre-transplant and post-transplant.

Some of the post-transplant clinical trials currently are CTOT trials, or the Clinical Trials in Organ Transplant, that offer possible therapies or trials looking at pushing off or saving you from chronic rejection of the lung, basically. These trials are really fascinating and interesting and are of benefit to patients because right now we don't have any treatment for chronic rejection. But we have several trials here that are looking at possible treatments for chronic rejection or delaying chronic rejection, which is a significant issue after transplant.

So again, coming to an institution like the Cleveland Clinic, when you come early, we're able to offer you pre-transplant clinical trials, maybe in your area of ILD (interstitial lung disease) or COPD (chronic obstructive pulmonary disease). But then, even after transplant, there are many opportunities for you to participate in clinical trials and research.

Kenneth McCurry, MD:

Great. Thanks, Marie. We mentioned patients with complexities, certain diseases, those sorts of things that we feel we have the experience to manage and to accept for transplantation, but we also see a good number of patients with other organ issues. For example, patients with coronary disease who are being evaluated for a lung transplant. That’s a common issue and contraindication, I think, at some lung transplant programs. Even patients with other end-organ failure, for example, cirrhosis or kidney failure. Maybe you could talk a little bit about our perspective on those patients and dual organ transplantation that we do.

Marie Budev, DO:

Yeah. Dual organ transplantation usually refers to either needing a heart and a lung, or a lung and a kidney, or a lung and a liver or a combination maybe of all of those. But this is something the Cleveland Clinic has excelled at. Thanks to Ken and his surgical team, we've been able to also work with other surgical expertise at the Cleveland Clinic, our liver surgeons, our kidney surgeons, all of our surgeons, our heart surgeons as well. The heart part of it is taken care of, but we can look at doing bypasses if we're not considering multi-organ, doing valve repair.

But then, if a multi-organ transplant is needed, we have an excellent multidisciplinary team that crosses different specialties to consider multi-organ transplants and to have success in multi-organ transplants. We do on average probably the largest number of liver-lung transplants in the country right now. We are also a leader in heart-lung transplant as well. This is an area that our surgical team has led, and we have had great success with. Again, for patients that may need dual organs, we work in a multidisciplinary way to address both organ systems to make sure you get the best care possible.

So Ken, can I ask you a little bit more about some of these patients that are high-risk, that may need a bypass or may need a valvular repair, and how we address those patients from a cardiac standpoint?

Kenneth McCurry, MD:

It's a pretty common circumstance I think, as you allude to Marie. The most common indication for lung transplantation in the United States is pulmonary fibrosis. That's a disease where the lungs have become scarred and shrunken a little bit and don't work well. It's common for the blood pressure in the lungs to go up for patients to develop pulmonary hypertension. Most of those patients are in their 60s, sometimes in their 70s, sometimes younger in some forms of pulmonary fibrosis. But as you well know, it's not uncommon in our society for people in that age range to also have other issues.

Coronary artery disease is a common thing that we see in general. There's a lot of concern about doing a lung transplant in the face of significant coronary disease. We've been very aggressive, given our expertise at the Cleveland Clinic in cardiovascular care and cardiac care in particular. We've been very aggressive at stenting many of the patients who have significant coronary disease and then getting them to a transplant.

As you allude to, we've also been quite aggressive in appropriate patients at doing combined procedures. Commonly, we'll do coronary bypass grafting and lung transplantation simultaneously in a good number of patients that we think are appropriate. Occasionally, as you allude to, if there are other valve issues, we'll address those at the time as well. Just because a patient has some cardiac disease, at our program, given our experience and our level of expertise on both the medical and surgical side, we're able to offer many of those patients a transplant.

Marie Budev, DO:

Ken, you alluded to the fact that IPF (idiopathic pulmonary fibrosis) is now the number one indication for transplantation in the U.S., and most of these patients are older. These are geriatric patients over the age of 65. I'd like to hear you talk a little bit more about how we manage these patients. We do have a wonderful geriatrics program that helps us. We have a “pre-hab” program that includes our own branded Cleveland Clinic pulmonary rehab program that anybody can access as a patient and a caregiver. But what other considerations have we taken into place to make sure that we have good outcomes in this patient population that's older?

Kenneth McCurry, MD:

Yeah, it's a great point, and as you sort of suggest, this comes back to our team approach that we discussed earlier and how we approach things at the Cleveland Clinic, being a team of teams. It's very common, as you well know, for patients who have progressive chronic lung disease, for them to have more and more difficulty getting around. That can lead to deconditioning, so weak muscles, a frail state that can make it very difficult and challenging to get through the rigors of a lung transplant program.

So, we have a very engaged geriatrics group who see all our patients preoperatively to assess them both from a physical and a cognitive standpoint. Then we have dedicated plans of therapy to try to optimize their physical situation, to put them in a physical state to try to optimize their outcomes with a lung transplant. We’re very aggressive at doing so and approaching that, truly, from a multidisciplinary standpoint, not only with the geriatrics group, but also the nutritionists and a variety of other people.

Marie Budev, DO:

For patients and caregivers, we are here for you. We want to be here for you and have every possible sort of answer to your many questions, so please reach out. Again, we're here for you, so please don't hesitate to contact us.

Kenneth McCurry, MD:

Thanks everyone for joining us today, and remember, every life deserves the best care.

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