George Makdisi1, Jin Ye Yeo2
1Cardiothoracic Surgery Division, Tucson Medical Center, Tucson, Arizona, USA; 2CCTS Editorial Office, AME Publishing Company
Correspondence to: Jin Ye Yeo. CCTS Editorial Office, AME Publishing Company. Email: ccts@amegroups.com
Editor’s Note
Current Challenges in Thoracic Surgery (CCTS) has published a number of special series in recent years, receiving overwhelming responses from academic readers around the world. Our success cannot be achieved without the contribution of our distinguished guest editors. This year CCTS launched a new column, “Interviews with Guest Editors”, to better present our guest editors and to further promote the special series. We also hope to express our heartfelt gratitude for their tremendous effort and to further uncover the stories behind the special series.
The special series “Lung Transplant: Current Status and Challenges”(1) led by Dr. George Makdisi (Figure 1) from the Tucson Medical Center has attracted many readers since its publication. This special series covered the most significant and challenging issues regarding lung transplantation and included renowned experts from different medical centers in the US to share their knowledge and experience. At this moment, we are honored to have an interview with Dr. Makdisi to share his scientific career experience and insights on this special series.
Figure 1 Dr. George Makdisi
Expert Introduction
George Makdisi MD, FACS, EMBA, MS, MPH, is chief of the Cardiothoracic Surgery Division at Tucson Medical Center in Tucson, Arizona, USA. Dr. Makdisi received his medical degree from Damascus University in Syria. He studied medicine in multiple prestigious teaching institutions and practiced surgery in 3 countries (Syria, France, and USA). Dr. Makdisi obtained three Masters’ degrees in Therapeutic & Pharmacologic Oncology, Public Health, and Medical Science &Information Technology, along with an Executive Master of Business Administration (EMBA).
He specializes in minimally invasive thoracic and cardiac surgery, heart and lung transplantation, and surgical management of end-stage and complex heart and lung diseases. He is actively participating in the training and education of the next generations of cardiothoracic surgeons.
His clinical research activities focus on optimizing short-term and long-term patient outcomes with a main focus on thoracic transplantation and mechanical circulatory support, as well as standardization and protocolization. He has numerous publications in peer-reviewed scientific journals and presented his work at national and international meetings. He enjoys his free time with his wife and three kids.
Interview
CCTS: What drove you into the field of cardiothoracic surgery?
Dr. Makdisi: One of my first patients in medical school clinical rotations was a female teenager suffering from cystic fibrosis. Her physical and psychological condition, O2 dependency, and inability to enjoy her childhood and teenage life were a life-changing experience for me and drew me to the field of cardiothoracic surgery and transplant. This was reinforced by one of my mentors who was a highly skilled individual and very dedicated to his profession. He was an exemplary role model. His character and charisma inspired me to pursue a surgical career. After all these years of practice, cardiothoracic surgery remains an exciting, stimulating, challenging, and rewarding specialty to me.
CCTS: Could you provide an overview of the current status of lung transplantation?
Dr. Makdisi: Lung transplantation has a long, and thrilling history, with continuous progression in better outcomes due to a better understanding of lung rejection and immunotherapy, along with the significant role performed by lung transplant organizations. Although lung transplants continue to rise in number and progress due to multiple factors including new technologies, drugs, increase of devices used to support the lung, and extended criteria, there is a lot that still needs to be done.
CCTS: What are some significant challenges of lung transplantation?
Dr. Makdisi: The main challenge in lung transplant “like any other organ transplant” is the shortage of lungs available for transplant in contrast to the needs, resulting in an increasing number of patients on the waiting list.
The lung is the only transplanted solid organ that is in constant exposure to the extracorporeal environment through inhaled air. Along with immunosuppression, these make the transplanted lung vulnerable and at a constant risk of infection which continues to be a big challenge.
The decrease in long-term survival compared to other transplanted organs is a big defy for all of us. This starts with a better understanding of factors affecting the short- and long-term outcomes, such as primary graft dysfunction (PGD), bronchiolitis obliterans syndrome (BOS), chronic lung allograft dysfunction (CLAD), and restrictive allograft syndrome (RAS).
One of the other concerns is the decision between single vs. double lung transplant is sometimes affected by organ availability rather than well-defined criteria.Other important concerns in the lung transplant field are the ethical issues related to donation with cardiac death, the donor selection, and the rationale of offering lungs to patients at higher risks with well-documented lower survival outcomes, rather than patients with better expected outcomes.
CCTS: Could you share more about how this special series contributes to addressing some of the challenges you mentioned earlier?
Dr. Makdisi: In this special series on lung transplantation, we have assembled an outstanding group of US and international physicians and leading experts in the lung transplant field to discuss these challenges in the field. We have provided the summit of their expertise in lung transplant. This includes best practice in all the steps of the lung transplant process from patient selection candidacy to long-term follow-up, such as donor and patient selection, best practice in expanding lung transplant, and the use of extracorporeal membrane oxygenation(ECMO), ex vivo lung perfusion (EVLP), and Organ Care System (OCS) for lung restoration and recipient support before and after transplant. We discussed the ethical aspects of transplant and lung transplant such as the decision about recipient selection and donation with cardiac death, which have rarely been discussed before.
CCTS: What are some of your aspirations for the future of lung transplantation?
Dr. Makdisi: Despite the increase in lung transplant volume, unfortunately only 20-30% of available organ donors become lung donors worldwide. This is much lower than the rate of other organ donations. As we master the outcomes, we should be more liberal and aggressive in extending the donor criteria, while maintaining safety, to increase the donor and transplant volume.
I hope a worldwide change in legislative laws to make donations with cardiac death occurs more frequently. More efforts regarding making pro-organ donation laws worldwide will be greatly welcomed.
Mesenchymal stem cell therapy for lung transplantation is an inspiring strategy in treating BOS to induce remission in refractory moderate to severe lung rejection. The ultimate goal is the ability to use tissue engineering to generate functional human tissue (in vitro or ex vivo) that has preserved organ architecture and is non-immunogenic to prevent organ rejection. In the meantime, we should continue to focus on better transplant protocols, better immunosuppression drugs, and management of PGD, BOS, CLAD, and RAS.
Having closer collaboration and communication between diverse transplant care teams has a pivotal role in receipt management and eventually will translate into better outcomes and survival, especially the short-term mortality and morbidities, but also in long-term outcomes.
Better collaboration between lung transplant organizations in geographically nearby countries might lead to open borders for transplants which might increase the donor pool leading to an increase in transplant volume.
CCTS: If given the opportunity to update this special series, what would you like to moderate, add, or emphasize to provide a more comprehensive series?
Dr. Makdisi: I think the article on COVID-19 is an excellent article. I realize that it was challenging for the authors to write an article at a time when we don’t know much about COVID-19, but I think an update about COVID-19 and the safety of lung transplants in COVID patients is a subject worthwhile to visit again. With the literature revealing good outcomes, it might be a good idea for the journal to generate more discussion about the use of mechanical devices of support in lung restoration and patient support.
Despite the new promising immunosuppression treatment, patient support, and clinical trials in lung transplant being discussed in each corresponding article, having a separate article discussing the new drugs, devices, protocols, and clinical trials might be a good quick reference and up-to-date information for the readers. Another subject that deems interesting to revisit is the ethics in transplant, which is also a major subject in which some aspects were rarely discussed prior to this series.
At the end, my coauthors and I would like to thank the CCTS, for giving us the opportunity to deliver our experience and knowledge to readers, we hope the series will start a constructive discussion about lung transplant and transplant in general.
Reference
- Lung Transplant: Current Status and Challenges. Available online: https://ccts.amegroups.org/post/view/lung-transplant-current-status-and-challenges