By F. Perry Wilson, MD, MSCE

I am Dr F. Perry Wilson. I'm an associate professor of medicine and public health at the Yale School of Medicine. I am joined today by two amazing physicians, Dr Rade Tomic, who is a professor of medicine, pulmonology, and critical care and medical director of the Lung Transplant Program at Northwestern Medicine. I am also joined by Dr Ankit Bharat, the chief of thoracic surgery at the Canning Thoracic Institute and a professor of surgery at the Feinberg School of Medicine at Northwestern. Gentlemen, thank you for joining me to discuss what is really an amazing case that came out in the news: a lung transplant, the likes of which I don't think has ever been conducted in the United States. I want to jump in and ask Dr Tomic to start us off and tell me a bit about this patient, Davey Bauer. Who was Davey Bauer?

Rade Tomic, MD: David Bauer, the patient, had a history of vaping and multiple infections, first viral infections and then Pseudomonas pneumonia. He had a really severe infection in both lungs. He was ventilated but the ventilator was not sufficient to keep him alive. He was then placed on the extracorporeal membrane oxygenation (ECMO), and he was dying on the ECMO, with no other options for him at that time. He was failing antibiotic treatments, and unfortunately, ECMO was not bridged for his survival or improvement.

Wilson: Let me dig in there a little bit. This is a 34-year-old guy who's essentially healthy, except that he had been a cigarette smoker and a vaper and came in with influenza A. This isn't particularly unusual, but obviously, complication after complication led to ventilator-dependent respiratory failure. I have, unfortunately, taken care of a number of patients on ECMO. Dr Bharat, what was the decision making like to put a patient on what is essentially cardiopulmonary bypass but not for a cardiac procedure?

Ankit Bharat, MD: ECMO is a mechanism with which we can provide replacement for failing lungs or failing hearts. It's essentially the highest level of heart-lung support that we can provide any patient with heart or lung failure. Patients like David Bauer, who have respiratory failure and develop some kind of injury to the lung, are not able to maintain gas exchange and oxygen levels. We typically put them on a ventilator, but there comes a point where the injury becomes so severe that even the ventilator cannot really provide enough support. The next and the highest level of support is ECMO.

Wilson: These patients are so sick that the mortality rates associated with ECMO are exceedingly high, even in young people like Mr Bower. The hope, of course, is that bypassing the heart-lung system allows the lungs times time to heal and eventually you can wean the patient off ECMO, back to the ventilator, and then off the ventilator. But this was not the case for Mr Bauer. His lungs were not healing. What was going on in your mind when you saw that his lungs were failing?

Tomic: It was obvious that his body was on maximal support through the ventilator and ECMO; yet, he was doing worse. ECMO was not a bridge to recovery for him, so the only option was a lung transplant.

And we had to do that in a manner that could keep the blood flowing through these artificial channels without clotting off. As sick as he was and how much scar tissue he had as a result of infection, if we had put him on blood thinners, which is conventionally standard for ECMO, he would have bled out to death. That's what we had to create using a strategy of artificial lung that has not been described before, although the idea has been conceptualized.

Wilson: I appreciate your modesty that people have thought of doing this before, which is fair enough. But to actually do it takes a lot of guts.

Dr Tomic, you created a physiologic scenario that is not typical, which is a heart beating in a chest cavity in the absence of lungs stabilizing it from either side. With Dr Bharat, you improvised a technique to keep the heart in place. This has gotten a lot of news because of how clever it was. But tell us, how did you keep the heart stable in the center of the chest?

Tomic: All the credit goes to Dr Bharat for this idea. We got the largest breast implants we could get from our plastic surgery colleagues and placed them on either side of the heart to stabilize the heart in position while we were waiting for donor lungs to arrive.

Wilson: Dr Bharat, that came to you in a flash? Or were you ruminating on what to do about this for a while?

Bharat: We thought a lot about how to maintain the blood flow. We didn't have a lot of time; he had a cardiac arrest and we had to do something in the matter of a few hours. So I ran many different configurations. I actually still have some of the renderings I made for how we would recreate the channels in the heart and all of that. Fifty-seven different configurations later, I thought, I could figure something out that that would maintain his heart functioning in his body. But what I hadn't anticipated — and the team didn't anticipate — was how it would look when we took the lungs out, and the risk that would be associated with.

Once the lungs were out and we created the channels, we realized that the heart would fall to one side. One of the normal functions of the lungs is to keep the heart right in the center so that it doesn't herniate and fall over. It was a scenario we had never experienced before, so we had to improvise. We were thinking about how to stabilize the heart. What was the biggest thing we could put in the chest cavity, and what could be the biggest thing that we could put in the chest cavity, and that was breast implants. So we got them and inflated them to the right size to fit his chest cavity. He was thin and tall and had a pretty big chest cavity, so it worked out.

Wilson: Dr Tomic, how long was it before donor lungs were available?

Tomic: It was a little more than 24 hours. Dr Bharat made an exceptional effort to get lungs for this patient. We were trying to get them as soon as possible, so we communicated with other centers to get them in a timely manner.

Wilson: The breast implants were removed, and the lungs were put in. I know that it was a long recuperative process, but can you let us know how he did, in broad strokes, and how he is doing now?

Tomic: He's doing great. Just before this meeting, I looked at his pulmonary function tests, and every single pulmonary function test after the lung transplant is getting better and better. He's doing exceptionally well.

Wilson: And he is out of the hospital?

Tomic: Out of the hospital, out of rehab, and here, at his temporary home in Chicago and doing really well.

Wilson: I hope still with his significant other.

Tomic: She is actually the key person who is getting him through all of this. Every single step of the way, and everything that he went through, she was a great support and help.

Wilson: It really is a story of many people coming together: multiple guardian angels. For those of us in medicine, because we're inundated with patients and office hours and people in the hospital, we are tempted to not take the kind of time that you both took and not go to the extraordinary lengths that you all went to. To be honest, if you had said: "Oh, it's too bad he's not eligible for a lung transplant because he's too sick" and he would have passed away no one would have batted an eye. That kind of thing happens all the time.

First of all, want to say congratulations, and thank you. It's inspiring to see someone working so hard on so many levels for just one patient. How do you keep that kind of focus in the current healthcare environment?

Bharat: We remind ourselves why we went into medicine, what was the most important reason. Obviously, there are a lot of distractions and pressures. But if we go back and stay true to what got us into medicine, that helps us understand the efforts that we need to put in. At least that's the message we try to create here. We pride ourselves on aspiring to be a destination of hope for patients. Our motto is that while we're trying to innovate, to move the field forward, we never lose the perspective that every life matters. David Bauer might not move the needle in terms of statistics, but for his family and his significant other, he's their world. We have to keep that in mind when we look at individual patients and not get bogged down by lots of other distractions that we constantly face every day.

Wilson: Thank you for reminding us of that. Thank you for the care both of you gave to this very lucky patient. Someone who, in almost any other circumstance in the world, would not be with us anymore, but who is going to be celebrating the holidays. And I'm sure he's very thankful as well. Dr Rade Tomic and Dr Ankit Bharat from Northwestern, thanks for spending some time with me today.