Bridge to transplant using a flow-adaptive extracorporeal total artificial lung system following bilateral pneumonectomy.

Summary

Single-patient proof-of-concept of a flow-adaptive extracorporeal total artificial lung (TAL) that enabled bilateral pneumonectomy for source control and bridged a patient with necrotizing pneumonia and refractory septic shock to successful lung transplantation. Paired single-cell and spatial transcriptomics of the explanted lungs revealed diffuse inflammatory infiltration and end-stage fibrotic signatures consistent with irreversible injury.

Key Findings

• A flow-adaptive extracorporeal TAL permitted bilateral pneumonectomy and maintenance of physiologic transcardiac flow until lung transplantation in a patient with refractory necrotizing pneumonia.
• Vasopressor requirements resolved after pneumonectomy, enabling hemodynamic stabilization on extracorporeal support.
• Single-cell and spatial transcriptomics of explanted lungs revealed diffuse neutrophil and monocyte-derived macrophage infiltration, activated T cells, expansion of aberrant basaloid epithelial cells and CTHRC1+ myofibroblasts consistent with end-stage fibrotic lung disease.

Clinical Implications

Provides a potential salvage pathway to bridge selected patients with medically refractory necrotizing pneumonia/ARDS to lung transplantation; suggests early consideration of extracorporeal TAL in otherwise non-transplantable cases and supports use of molecular profiling to assess reversibility.

Limitations

• Single-patient case report limits generalizability and does not provide comparative outcomes or safety in a larger cohort.
• Long-term device-related complications and reproducibility of the surgical strategy across centers remain unknown.

Future Directions

Prospective studies and multi-center registries to evaluate safety, reproducibility, and patient selection criteria for TAL-facilitated pneumonectomy, plus mechanistic studies to identify molecular markers distinguishing recoverable vs irreversible lung injury.