key: cord-0980707-cnorwoku authors: Rabi, Alireza Seyed; Muniappan, Ashok title: Commentary: Crossing the Rubicon—pre-emptive recipient bilateral pneumonectomy and delayed lung transplantation date: 2022-02-22 journal: JTCVS Tech DOI: 10.1016/j.xjtc.2022.02.004 sha: 2f4038fc96b98f83d8ed03d34e30b3c07d28b047 doc_id: 980707 cord_uid: cnorwoku nan onset and with cycle threshold values>24 (indicating lower viral load) rarely produce culturable virus in vitro. 9 Moreover, there is a report of lung transplantation in a SARS-CoV-2-positive patient (PCR cycle threshold ¼ 33) who avoided recurrent infection. 10 Separately, virologic sterilization via pneumonectomy might be impossible since SARS-CoV-2 does not solely replicate in lung tissue. [11] [12] [13] Evidence of viral replication has been found in lungs, central airways, central nervous system, heart, liver, kidney, and pancreas. [13] [14] [15] Ghodsizad and colleagues 16 found the COVID-19 PCR test was still positive 3 days postpneumonectomy, suggesting that there were potentially other sources of virus. While pneumonectomy is unlikely to lead to immediate clearance of virus, future investigations should examine whether pneumonectomy instead reduces a source of dysregulated immune response to SARS-CoV-2. 16 Supporting a "lung-less" patient requires judicious planning and meticulous execution, which Ghodsizad and colleagues achieved with a novel venous-arterial ECMO circuit. In addition to draining the right atrium, the authors placed an additional drainage cannula in the pulmonary artery to decompress the right heart, prevent blood stasis, reduce right ventricular afterload, and maintain pulsatility. A patent foramen ovale ensured decompression of the left side of the heart. This current approach appears simpler Ongoing COVID-19 infection is a contraindication for lung transplantation. Bilateral pneumonectomy and extracorporeal support before lung transplant have been performed for such a patient. than the other reported solutions for managing the "lungless" patient as it obviates the need for an additional circuit, 3 theoretically reducing thromboembolic risk, or a vascular anastomosis between the pulmonary artery and veins, 2 reducing complexity of pneumonectomy and subsequent implantation. As most patients do not have a preexisting patent foramen ovale, the left heart could be decompressed via atrial septostomy, open surgical placement of left ventricular vent, or a catheter-delivered intracardiac pump. 17, 18 Notwithstanding the clinical and ethical concerns, 7 lung transplantation has been used in a significant number of patients with COVID-ESLD. 6 While remaining SARS-CoV-2 viral load poses a risk of recurrent infection in lung allografts, this could be mitigated by new targeted antiviral therapies. 19 Pneumonectomy is unlikely to achieve complete clearance of infection but could help curtail a dysregulated immune response to infection, thus providing a rationale for staged lung transplant, and requires further study. The extracorporeal support of a patient without lungs requires careful preparation and can involve cannulation strategies suggested here by Ghodsizad and colleagues. 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