We spoke with Philippe Lemaitre, MD, PhD, surgical director of the Lung Transplantation Program at the Center for Advanced Lung Disease and Transplantation, about the state of lung transplantation, extracorporeal membrane oxygenation (ECMO), and other important subspecialties within the thoracic surgery field.
The Present & Future of Lung Transplant Surgery
What are your goals for the lung transplant program?
Over the last few years in this program, we have seen a progressive and steady increase in our lung transplant numbers. We have been gaining roughly 10 to 15% a year; we have been steadily ramping up through 2023 to rank number three in transplant volume nationally. And the first data we have for 2024 shows our numbers are on a steeper rise, which is great. We hope that we can sustain those numbers and potentially rank number one nationally.
But I don't think that the numbers are the goal in itself; If we achieve top ranks nationally, then fine by me. But the goal is to do what's best for patients. To me, it's actually not surprising that both are coming together.
I think it's just a reflection of the program's commitment to achieving what's best for the patients. It shows that we are successful in listing sick patients, in not denying anyone a chance at transplantation, and in pushing boundaries of what is currently possible with complex conditions.
What is one way you're pushing those boundaries?
Technologically, there's been a change lately in the way we've been maintaining organs, from when we harvest them to the time we transplant them. Previously, to preserve the lungs, we were using cold static perfusion at a temperature of four degrees. Now, we have research showing that a steady 10-degree fridge is best for preserving the lungs. When compared to lungs that have been preserved at four degrees for a short amount of time, we have had comparable early, midterm, and even long-term outcomes for lungs preserved at 10 degrees for a longer amount of time.
We have been doing this for a few years now in an effort that was initiated by Dr. Frank D'Ovidio, MD, PhD, the director of the Ex-Vivo Lung Perfusion Program here at Columbia. We now have been routinely using this for nearly all of our cases.
Why is this change important?
It improves general patient management in that we can move transplants into semi-elective cases while managing more complex cases. It allows us to optimize our transplant schedule so that everyone is at their best. These complex cases can be done in the daytime, when we have refreshed and fully loaded surgical anesthesia and nursing teams, as opposed to being pushed into doing these cases in the middle of the night.
So it's better for everyone. It's been shown that it's better to have refreshed teams providing care for complex patients. And so that's what we can do, and that's to the benefit of the transplant patient population, the recipient population. That's to the benefit of the surgeons.
Needless to say, if we don't have to start a very difficult case at 10:00 PM and finish at 7:00 AM, it's better for everybody.
It also helps us deliver timely care for all the other patients on the thoracic service. Now, when we have donors early in the night, then we push the case for the transplant to the morning to avoid transplanting in the night. And when we have donors in the early morning or at the end of the night, we can delay the transplant until we've taken care of those other patients who need lung cancer operations or other cases that also require timely care.
What was happening prior was that those patients needing a cancer operation would be bumped when we were doing a transplant. So then they would have to be rescheduled, which is unpleasant for them as well.
We can now get everybody done in a timely fashion. And so it helps us provide improved care to all of our patients, not just transplant patients. That is a dramatic change for us, and everyone benefits.
How does that temperature change affect the organs?
To be clear, it's very specific to the lung; it does not apply to other organs. However, studies have shown that 10 degrees is the best way to sort out the mitochondrial activity; it slows down the power source of the cells to its least active state. However, it also does not put the cell at a temperature that is too cold, where we see signals that drive cell death. There's a balance between the two that is favorable for preservation.
Again, it's purely related to the lungs. But this is really the dominant change in lung transplantation, and we are one of the most active centers in the United States regarding this practice.
Can you tell me about research at the center?
There's a great research effort being carried out by Dr. Dovidio about the 10-degree cold static perfusion, alongside his prior research regarding how we can best assess and treat reflux in the transplant population. We've been pushing for anti-reflux operations in our transplant patients to protect them from recurrent graft injury from the refluxed gastric compounds that can trigger rejection.
On my end for research, I have been doing clinical research about patient outcomes. While I hope I can keep working on research projects, right now, really, it's more about clinical patient management for me. That's the transplant cap that I am holding.
Looking at the state of lung transplantation from a broader perspective, what are the biggest challenges for transplantation today?
Organ availability. In fact, I think the most return will come from the money and efforts that are put currently around the evaluation and assessment of what are called marginal organs. These organs don't fit the perfect picture of a young, non-trauma, non-smoker with perfect gas exchanges and perfect bronchoscopy; that perfect fit only happens in a very small number of cases. There are a significant number of cases where we have marginal donors, and there's a great deal over the last ten years of activity that has been aimed at pushing the limits of using these organs. It's been very helpful because we now know that we can use lungs that are not perfect fits with great success. So, in pushing this boundary, I think the lung transplant community has been doing a great deal of work to find organs for patients.
But I think another great avenue that should be emphasized to help us get organs is this: we need more advertisement for organ donation. If you imagine a hundred donors here in the U.S., we know that only 20% will become decent lung donors because the lung is a fragile organ.
We can ramp up from those 20 to 25 donors by pushing for more marginal lungs with very expensive machines. But with an additional effort getting the word out there, we can get 200 donors just because families are open to organ donation. When there's a broader consideration of organ donation in the population, then we will dramatically increase access to organs because we will double the number of patients that are screened.
That is valid not only for the lungs but also for all the other organs. Organ scarcity is a problem for every organ. So I think the political effort to get the word out there saying, "Please become an organ donor," is probably where the return on investment might be the best. Of course, the campaigns will be extremely costly to start with, but the return would be worth it.
What about on the transplant team side?
I think we should keep pushing to have more teams going out and assessing organs. The paper forms, the records, only tell part of the story. So, we strive to send out our team as frequently as possible to assess these lungs. I recognize the effort of the team here, but if programs can send more teams out and assess more organs, that would be helpful as well. The more we assess the organs, the more we're going to find some that we might have missed.
Where do you think the next breakthroughs will come from?
I think one area is patient management research about rejection, making sure that organs that are transplanted get the best possible outcome by understanding the rejection mechanisms and how we can circumvent them. Possibly, our current understanding of immunology is close, but maybe more so in the future. A great deal of research is being carried out right now to understand this.
What about further down the road?
In the future, I hope that the lungs will benefit from xenotransplantation, as has been shown to be possible for the kidneys and heart in the advertised research. That would clearly play a huge role in our prior discussion about the donor pool.
I would say I'd be happy to see that occur in my career; I think that timeframe is reasonable. It's just so complex to have these organs crafted. The pigs that are used must be, genetically speaking, extremely modified just to pass the barrier of the first five seconds of organ reperfusion. The proteins are so different that if you don't have a massively genetically modified pig, the first thing that happens is blood clots form after the first blood pass. It's literally that fast.
The contact surface between blood and cells in the lung is so broad that it probably presents more issues than in other organs. And it's not only the blood contact on the vascular side, but it's also the contact of the organ with the outside of the body, with all the air, with all the crap we breathe in the air around us that can trigger inflammation. And inflammation can trigger rejection. The relationship between the two makes the lung a fairly complex organ to manipulate.
Right now, it's not something that is ready for prime for the lungs yet, given all the hurdles that have to be managed to be cleared to get these organs into the human body. I would be thrilled to be proven wrong in that perspective because it would change so much.
As a surgeon, I say, give us shelves of lungs, and we'll do the transplants. We are currently denying patients lungs because we have a scarce resource; we have to prioritize allocation of the organs. If we give to patient A, we cannot give to patient B, so we have to make as fair a judgment call as we can by anticipating how patient A will do as opposed to patient B.
On the one hand, we operate on transplant patients nowadays that we would have rejected 10 to 15 years ago, back when I was starting. But there are still a lot of patients to whom we must say we cannot help you, and it would be great if we could help most, if not all, of them.
So I am optimistic, but for now, we will still have to rely on the conventional human donor pool for the foreseeable future, which is where I think a political push is probably in the best interest of the community.
Columbia has a reputation for complex cases, taking on some of the most difficult transplants, multi-organ transplants, and very difficult scenarios. Do you feel that there's anything specifically different about Columbia's approach that allows this to happen?
Yes, and I appreciate that on a daily basis. Working in this environment, I think number one is that we attract and concentrate the resources needed to achieve the best outcomes for complex cases. You need to have people around you who can do it. Columbia has so many nationally renowned programs: a great cardiac surgery program, a great liver program, a great kidney program, and a great lung program. When you put all of these together, the skills are concentrated here.
I appreciate the open-mindedness of the people here and their willingness to work together to help patients who need a rare combination of skills.
It's good to have the skills, but if you have people who say, well, I just want to do X, Y, Z in my field of expertise, but I don't wanna work with others, it doesn't work. So not only do you need to have the skills in-house, but you also need to have the will to collaborate with each other to open the door for those complex cases.
I think what makes us unique: this combination of the array of skills available and the philosophical way with which those doctors, nurses, and all the teams are also willing to work together.
That's something I really appreciate about working here, and I am very proud of being part of these teams. I think the Columbia Transplant initiative led by Dr. Tomoaki Kato is really something that is reflective of a further institutional will to bring all of these skills together, from top to bottom.
I just had a lung-kidney transplant and had a great collaboration with the kidney team, and I was very appreciative of that. We are listing our fourth patient for heart-lung, and one of them is needing a heart, lung, and liver. All of this requires great relationships between all the teams. There's also currently great support from Columbia’s leadership to move [the level of care] forward for our patients. So, I think we are geared up to keep delivering optimal care for very complex patients because our environment has what is needed to make it successful. It really is not common.
Advances in ECMO
You wear more than one cap, correct?
Yes, I'm also the surgical director of the thoracic ECMO program [ECMO, or Extracorporeal membrane oxygenation, is a machine that can support the function of the heart and lungs]. That role allowed me, if I may say so, to take care of the sickest of the COVID-19 patients during the pandemic. Now, we are seeing a return of the other more historical indications for ECMO, like conventional acute respiratory distress syndrome (ARDS), pneumonia, and common viral illnesses such as the flu.
And, of course, there are a great number of ECMO cases that are driven by our busy transplant activity. So on those grounds, we're still a very busy thoracic ECMO program here. We work in collaboration with the cardiac ECMO program to manage the most complex patients, some of whom are bridge-to-transplant.
We are one of the few programs that offer ECMO transport. We go out to other centers where patients are sick, cannulate the patients at the outside center, and then repatriate the patients to Columbia to provide ECMO care here.
The last part of my activity is providing general thoracic care for general thoracic surgery: oncologic surgeries, mediastinal surgeries, and tracheal surgeries. However, the transplant activity has become my core focus.
The ECMO program here is an ELSO-designated platinum center of excellence. What does it take to achieve that distinction?
ECMO is a complex patient care tool, so to have a successful complex patient care center, you need to have a great collaboration between the people who have the skills to put the patients on ECMO and the team to take care of them afterward. And leadership needs to be willing to accept these patients. As I mentioned, other centers typically don't do ECMO transport, but we do. That open-mindedness is extending our reach to more patients, to their benefit. Columbia's leadership has been supportive of creating and maintaining the program. And, of course, training is key. I've been training fellows for ECMO management for almost six years now.
From a technological perspective, are there any developments in ECMO that you're anticipating?
There are frequent technological advances with ECMO, such as getting different cannula sizes [a cannula is a small tube used to connect the ECMO machine to the body] and shapes that are very useful in certain indications. I think every time these tools are coming out on the market, some people believe that it's going to change the game completely. I think what transpires is both access to new options and a better understanding of what you can do with what is already available. I think on those grounds, we have been at the forefront of what is possible with ECMO, in parallel to those technological advances. We did not wait for the technological advances to keep pushing what was possible with what was available.
From that perspective, I'm predominantly thinking about the lung transplant population, where we have tremendous experience in bridging patients onto ECMO for lung transplantation. These are patients who are failing optimized medical therapies and are listed for transplants. And so when they are failing these therapies, they may need ECMO before we can bring them to the operating room.
Science has shown that it is best to have these patients mobile, awake, and ambulatory while on the ECMO bridge. And that is something we've been doing for many years now. This requires quite a bit of ECMO flow. So, the device needs to perform fairly well, and we use pretty big cannulas to flow nicely to keep the patient stable. But then we wake them up, and we walk them around.
Do you work with the pediatric teams for ECMO?
Pediatric ECMO is a very specific caring environment. Believing that a child is just a small adult is absolutely wrong. So, it requires specific skills. I have skills to manage the taller pediatric patients, but I'm not a pediatric surgeon. And so, the finesse of the care there is slightly different from what I am doing. We have a tremendous pediatric ECMO program led by William Middlesworth, MD, and a great pediatric cardiac surgery program at our Morgan Stanley Children's Hospital. And if Dr. Middlesworth comes a little bit at the edge of his comfort zone with a pediatric case because it's a taller or heavier patient, I help him. So we help them with a few cases a year. In turn, we may ask for help. It's a great collaboration.
There is a will here to keep offering pediatric lung transplantation, but that is not such a frequent indication. I think we have the skill sets and the bandwidth to transplant young patients, even infants, but that requires a bit more effort right now. It's a very specific patient population.
For now, I'm very happy with what we are achieving on the adult side.
Lung Cancer & Robotic Thoracic Surgery
How are advances in cancer care affecting the thoracic surgery space?
Some tremendous changes in lung cancer care have been occurring over the last few years. One is the development of new therapies that were initially targeted for advanced lung cancers, which are now translated into less advanced cancer patients. These are immunotherapy treatments that promote the immune system's response to lung cancer and other thoracic malignancies. These treatments are completely changing the landscape of lung cancer care management. And even if it's a drug, it has implications for the surgical field because if it changes the medical management of patients, it then changes the surgical management, as well.
And I think we are far from having harnessed the full capacity of these medications. In the thoracic field, it seems like not a single day goes by when there's not a paper coming out showing a new or better application. That is really changing the general management of lung cancer and thoracic malignancy care, and with it, the surgical management as well. And I think that's going to keep changing in the years to come.
The second is the constant development and refinement of robotic surgery in the chest. The effort here is led by Dr. Bryan Stanfier. I think Dr. Sonett is embracing the technology as well, and Dr. D'Ovidio has been using it for a long time.
Do you think robotic lung surgery will replace traditional surgery anytime soon?
I think there are cases where it's perfectly suited, and there are cases where it may not be that useful. More research in the field is needed to know where the perfect comfort zone is.
Robotic surgery is just another way to do it. I think it's more comfortable for the surgeon who's very comfortable with the technology, and you do see a split of sorts. There are some surgeons who have moved to a full robotic practice.
I believe there are situations where the robot is clearly better than conventional surgery. For example, a robot is a great tool when you work in a conical structure, like the pelvis or the upper GI tract, where it meets the chest or the upper aspect of the chest: the pulmonary hilum or the pulmonary apex. However, the rib cage is very wide, which is not ideal. So, I think the robot is going to add a ton more value for some operations in the chest than for others.
I had a patient recently who had a chest wall tumor that needed to be resected, and the area where this was located was best suited for robotic surgery. So, I referred her to Dr. D’Ovidio to do the operation because that was what I believed would be the optimal way for her.
So, there are certain procedures in the chest that are best suited to a robot. Whether the more conventional operations in the chest will, at some point, be best suited with a robot, I'm not absolutely convinced. But if you ask me when I'm 65 and I need my prostate removed, whether I want it robotic or conventional, I can tell you it's robotic, a hundred percent. But that's because I think this is where the robot performs the best.
It's really a fantastic instrument, but whether a fantastic technological advance translates strictly into better patient outcomes in all areas of application is another story. It performs tremendously well in some indications as of right now, but there will always be operations in the chest that require traditional expertise.
To be able to do both will be a challenge. It will take some humility for the old-school surgeons to learn a new technology and for the new-school surgeons to accept that they still have to keep some old-school skills and learn more conventional stuff.
Growing A Sustainable Lung Transplant Program
Where would you like to see the Transplant Program in five years?
I think that over the next five years, we will strive to have sustainable growth. What will be difficult for us is continuing to grow as we've been doing while, at the same time, continuing to deliver the same optimal patient care. The mistake we must avoid is overdoing one aspect of care if it comes at the expense of another.
Here is a simple example: We were counting the other day the number of bronchoscopies that are done every year, which are done as part of post-transplant care. When we increase the number of transplants a year by 10%, it increases the number of post-transplant bronchoscopies needed by 200 a year. These bronchoscopies are necessary to watch a patient’s progress after their transplant.
So, three years ago, we were doing 80 transplants and roughly 700 bronchoscopies a year with all the patient population that had accrued over time prior. Then, 15 more cases a year later, with a few years with increased numbers from 2021 to 2022, the number of bronchoscopies went from six or seven hundred to over a thousand.
Currently, our numbers would make us jump not by an increase of 10% for next year but by 20%. So that means we would double the number of bronchoscopies, which would put those numbers closer to 1,500.
If we are not capable of delivering these bronchoscopies , then our quality of care is going to go down, and the five-year outcomes for our patients are not going to be as great. So, while we can do the transplants, the problem is the rest needs to follow.
The difficulty here is associating the concept of growth with the concept of sustainability at the highest level of quality. We need to have a programmatic approach to this that makes it sustainable. With high transplant numbers, it's going to look shiny for a while. But in five years, if survival goes down, then I would be disappointed by that. It's a real team effort to address more complex cases and have the same outcomes. And this is where we will put ourselves really at the forefront if we can achieve both at the same time.
That's the reality of what we have to do. There's no genius robot that's going to help us do that, no great ECMO cannula that's going to come on the market that's going to be a revolution to lung transplant or ECMO. It's blending all this great expertise in the same place and making certain that we grow in a sustainable, safe way. Whether I get it right, we will only know five years from now. But I am confident we will succeed.
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