COVID-19 related lung disease, Mobile ECMO (Extra Corporeal Membrane Oxygenation) Therapy

Fred Rahmanian

Fred Rahmanian's Lung Transplant Journey

On some of the worst days of his battle with COVID-19, Fred Rahmanian remembers waking up in his hospital bed to look at photos of his wife and three kids that someone had lovingly taped to the wall in his room. Rahmanian was one of millions of Americans who got sick from COVID-19. But when he first went into the hospital in October of 2020, it didn't cross his mind it would ever get so bad. But it did, the virus damaged his lungs so badly that on New Year's Day 2021, Fred became the first patient with COVID-19 to receive a lung transplant at Penn Medicine, and the first in the state.

COVID-19 Complications

In October of 2020, Rahmanian, a 54-year-old husband and father of teenage triplets, was one of four people in his family to test positive for COVID-19. While his kids recovered quickly, he found himself in an ambulance on the way to his local hospital in Reading, PA, where he continued to get sicker and wasn't responding to treatment.

His condition continued to deteriorate, and on November 11 his condition deteriorated so rapidly that doctors deemed him too unstable to even transport to a tertiary center for more advanced care. That's when his local hospital called for assistance from Penn Medicine's Lung Rescue Mobile ECMO team, kicking off a long chain of Penn care that would see Rahmanian through to a remarkable recovery.

Lung Rescue in the Middle of the Night

Penn's Mobile ECMO team usually travels by helicopter to quickly pick up very sick patients, usually those with immediately life-threatening conditions. ECMO (Extracorporeal Membrane Oxygenation) provides functions normally performed by the patients' own heart, lungs, or both. It withdraws unoxygenated blood from the patient, oxygenates it, and pumps it back into the body — this oxygenation process removes carbon dioxide and replaces oxygen just as healthy lungs would.

There was one complication though, on that particular night; a storm raging outside made flight conditions impossible. So, the team pivoted. William Vernick, MD, co-medical director of the Penn Lung Rescue, Asad Usman, MD, MPH, a Penn Anesthesiology and Critical Care fellow, along with the PennSTAR Team, drove to pick Rahmanian up and take him back to the Hospital of the University of Pennsylvania by ambulance, hooking him up to the ECMO machine for the trip.

"Even though it was late at night, I remember the drive quite vividly. The rain was so heavy that I couldn't go more than 30 mph on the highway. It made for an extremely long drive, but seeing him do well definitely made it worth it," said Vernick.

After the surgery to place Rahmanian on ECMO, he recovered relatively quickly and was able to return home to his own bed while he worked on to rebuild his health and strength with Penn's Physical Therapy team.

A Last Chance, a Lung Transplant

After a few weeks on ECMO, it was clear to the medical team that Rahmanian's lungs were not getting better, his lungs had been too badly damaged by the COVID-19 virus. Maria M. Crespo, MD, medical director of the Penn Lung Transplant Program, helped care for Rahmanian during this most critical time. His team knew he had one option left to save his life: a lung transplant. Penn Medicine had never performed a lung transplant on a patient with COVID-19. In fact, it was almost unheard of at that point in the medical community globally.

"Fred's case was unique because although his lungs were severely injured by the virus, he was otherwise a healthy man. We were confident that with the care he would receive at Penn, he had a good chance of recovery, so we all worked together to make sure we got every detail right," Crespo said.

Hearing that is when Rahmanian said the gravity of the situation really set in.

"When I realized what they were asking me, that's when it dawned on me, this is the last of the options. Otherwise, this is it for me. My family had already resolved with the fact that that this was probably it if I don't decide to do the transplant," he said, recalling what went through his mind. "I want to see my kids' graduation, I want to see them turn 18, I want to see them go to college. There's so many things that we haven't done yet."

Innovative Team Approach to a Complex Case

Qualifying to be a transplant patient is complex under normal circumstances, but in this case the Penn team that surrounded Rahmanian was dealing with those complexities on top of a patient who was critically ill with COVID-19, a virus that the medical community was still learning about with a constant flow of new discoveries. Innovation among the transplant team was crucial.

One key aspect of transplant care is Infectious Disease. With Fred, and all through the COVID-19 pandemic, this team played an especially critical role. Sarah Longworth, MD, assistant director of the Transplant Infectious Disease Program, cared for Rahmanian during his treatment.

"As with any patient being considered for transplant, we want to make sure that recent infections are at minimum controlled, and at best fully resolved. This is true for COVID-19 as well, particularly in patients like Fred in whom this infection was the cause of his organ failure," Longworth said. "Since Fred was the first patient we transplanted for COVID-related lung disease, we were in uncharted waters with no clearly defined standard of care. He was tested multiple times for COVID-19 to ensure the infection had cleared before we proceeded to transplant, in order to minimize risk of re-infection of his new lungs."

Not every ECMO patient with COVID-19 can be considered transplant candidates. Because lung transplantation for COVID-19 patients was a new space in the medical community, a new list of criteria for patients to meet had to be developed by the team the Penn Transplant Institute

Fred Rahmanian In BedFor example, to qualify, candidates have to be under 60 years old if they're on a ventilator or ECMO, can't have more than one organ failing, and must have a BMI less than or equal to 35, along with additional guidelines. These specific lung transplant guidelines for COVID-19 related lung injuries were developed and issued by Crespo in collaboration with, Joshua Diamond MD, MSCE, associate medical director of the Penn Lung Transplant Program, and Christian Bermudez, MD, director of thoracic transplantation at the Penn Transplant Institute.

"Currently the stakes are high for lung transplants. First, there's the absence of enough organ donation to meet the need for lung transplants in the U.S. Further, there's the impact of patients who have been on prolonged ECMO support before they can become transplant candidates — for those patients, surgery can carry a high risk," said Bermudez, who performed the surgery.

A Lifesaving Lung Transplant

Within 72 hours of being listed for transplant, doctors found Rahmanian a perfect donor match. On New Year's Eve, 2020, Bermudez and his team went into the operating room for what would be more than six hours of surgery. Just after 5:15 a.m. on New Year's Day, Rahmanian woke up with a new set of lungs and a new chance to live. When he woke up, he took some of the easiest breaths he'd taken in months, and learned some additional news.

"I was told I made history, I was the first COVID-19 lung transplant in Pennsylvania!" he said. "This whole thing has been a miracle. Everyone knew I was at the end of the line. There was no expectation that I would live until Penn Medicine stepped in."

Usually transplant patients take six to eight weeks to recover in the ICU, but after just 20 days Rahmanian was taken to Good Shepherd Rehabilitation Center, where he continued his recovery.

"With an incredible mental and physical strength Fred was able to overcome adversity with the help of the ICU nurses, doctors, and physical therapists, and was in optimal condition for transplant after more than seven weeks of ECMO support. This hard work fortunately payed out as he had a swift recovery leaving the hospital only 20 days following his lung transplant," Bermudez said.

New Lungs, Renewed Life

Rahmanian FamilyOn February 24, 2021, Rahmanian spent the first night in his own bed since October 27, 2020. At the time of the surgery, fewer than eight lung transplant centers nationwide were performing lung transplants in COVID-19 patients with acute lung injury. As of March 2021, Penn Medicine was one of 28 hospitals in the United States that had performed heart or lung transplants for patients with COVID-19 according to the United Network for Organ Sharing.

"At Penn I felt very comfortable that I was being taken care of. Everyone that I interacted with was very helpful, very sympathetic. They essentially granted me a miracle by choosing to do this for me."

Rahmanian said from the moment he agreed to the transplant, his driving force to recover was his family. Soon after he returned home from his lung transplant, Fred felt so fortunate to be alive to see his triplets turn 18 and graduate high school. He looks forward to being a part of all their milestones in the years to come.

"At the end of the day I was grateful that I was given more time," he said.

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