Since its inception, the lung transplant program at NewYork-Presbyterian and Columbia has seen more than 1,600 patients receive organs. But, as one of the oldest and most experienced centers in the world, this did not come without some challenges. In the late 1980s, access to donor lungs was extremely limited which made transplanting patients difficult. Once joining the program in 2001, Dr. Selim Arcasoy and his team had a vision to change that. Over the course of two decades, the lung transplant team has been dedicated to building a robust program that utilizes years of experience and the latest tools to ensure that even the sickest patients have the opportunity to receive lung transplants.
The field of lung transplantation is relatively new with widespread lung transplants beginning in the early 1980s. Throughout the last forty years, it is a field that has rapidly evolved with drastic changes in lung allocation, or deciding who will receive the next available lungs for transplantation. Dr. Selim Arcasoy has led the NewYork-Presbyterian and Columbia Lung Transplant Program through these changes since 2001. Thanks to his dedication to improving lung allocation and foundational research, the program has been a catalyst in changing how lung allocation works in New York and beyond. These policies, in conjunction with Dr. Arcasoy's talented team, clinical research and state of the art tools, have led to greater numbers of patients receiving life-saving transplants.
For more information visit nyp.org/Advances
[00:00]
Catherine: When Dr. Selim Arcasoy first arrived at the Lung Transplant Program at NewYork-Presbyterian in 2001; it was facing serious challenges due to low volume. Dr. Arcasoy was one of the physicians brought in to revive it.
The first few years were difficult. In comparison to other organ transplants, lung transplantation was relatively new at the time -- widespread lung transplants only began in the early 1980s. There were still a lot of challenges with how lungs were allocated: as in which patients should be given preference on the waitlist and where, geographically, those lungs could come from.
Dr. Arcasoy, alongside his dedicated and growing group of pulmonary specialists, deftly navigated the changing landscape and advocated for stronger policies on lung allocation which would allow more access to life-saving transplants. Today, more than twenty years later, the Lung Transplant Program is thriving. [01:00]
I'm Catherine Price and this is Advances in Care.
This week I had the opportunity to speak with Dr. Arcasoy, the Medical Program Director at the Lung Transplant Program at NewYork-Presbyterian / Columbia about the evolution of the program and his role in advancing lung transplant in the U.S.
Catherine: First of all, welcome to Advances in Care. And thank you so much for making the time to speak with me today.
Dr. Arcasoy: Thank you.
Catherine: So I understand the Lung Transplant Program was facing some challenges when you started working at NewYork-Presbyterian. Can you talk a bit about the state of the program at that time and what it was like for you when you first started leading it?
Dr. Arcasoy: So the institution was trying to determine if they should continue with the lung transplant program that was actually running since late 1980s, since 1988 or so. And, actually this is one of the oldest programs in the world, dating back to late 1980s. It was mainly running with [02:00] individual efforts, medical doctors like me and surgeons.
The volume was always between 10 and 20, and the institution wanted to enhance that, enhance the volume, enhance patient outcomes. So Columbia and New York Presbyterian decided to start with a new team and new leaders and that's when I became the medical director here, along with Dr.Sonnet, who became the surgical director. We started mid to late, 2001. Our first few years, you know, we did, we gradually increased our volume, so the program grew from being a small mom and pop shop to a very large program with lots and lots of staff currently.
Catherine: So what were some of the challenges you faced when you first started running the Lung Transplant Program?
Dr. Arcasoy: When I started here, the Allocation system was time based only, so patients were seen and [03:00] got listed if they were deemed eligible, and they were placed on the waiting list. And as the waiting list grew, the waiting times climbed up to two plus years for individuals from time of listing to climbing to the top to be able to get a lung transplant. So the practice was really listing people early, as early as possible, so they accrued time before they got sick. And God forbid if you saw a sick patient in your office, who was on a lot of oxygen and didn't seem to be doing very well, that person had very little chance of making it to transplant. It was a tough time.
Catherine: So you mean hospitals were putting patients on the waitlist early before they really needed the transplant just so that if and when they did need a transplant they would have a better spot on the list.
Dr. Arcasoy: Absolutely. So final rule was what actually prompted the development of a lung allocation score system. And [04:00] indicated that lung allocation or organ allocation should be based on disease severity, and wait list urgency. It shouldn't be guided by geography. And that it shouldn't be futile, so you shouldn't be transplanting very, very sick people who had no chance of surviving after transplant. so it called for a lot. And, this is actually quite complicated, but it led to a system that started on May 4th, 2005 called the lung allocation score system. With lung allocation score system, lung transplant volumes increased dramatically, over the past decade and a half and U.S. transplant volumes reached about 2,500 transplants from 800 to 1,000 over that decade and a half.
Catherine: Was that due to the fact that it was easier to match the patients with the lungs or because there were more lungs or was the reason?
Dr. Arcasoy: Well, I think multifactorial. [05:00] I mean, one thing for sure is transplant centers became more comfortable transplanting sicker people. And as our, you know, surgical techniques and post transplant management became better, we started listing people we wouldn't have listed maybe 20 years ago. The system allowed for faster transplant, so when you listed a sick patient, you were able to transplant that person fairly quickly.
And then, and then I think the administrative burden diminished significantly. So, instead of making, I don't know, 20 phone calls to place lungs, they were making only 2 or 3 phone calls. So, this way lungs in a donor did not become unsatisfactory. Cause the, the sooner you procure lungs and transplant them, from a brain dead donor, the less inflammatory exposure they have and the better they do.
Catherine: So what was the patient population like at NewYork-Presbyterian at that time? Did the new process allow you to treat older and sicker patients? [06:00]
Dr. Arcasoy: When we first started, we started transplanting older patients, with a lot of careful thought and consideration. Wait time based system, there wasn't a whole lot you could do with like critical illness. And once lung allocation score system started in 2005, so four years after we arrived, we started feeling more and more comfortable with sicker and sicker patients. And when you look at our UNOS benchmark report, and this is partly something that we didn't necessarily want, but it's a geography factor.
Our patients became a lot sicker than the rest of the country. So we became a center with very sick patients with high severity index and our center was actually able to spearhead the concept of bridging patients to transplant using ECMO [07:00] technology, extracorporeal membrane oxygenation technology, back in the day. This was one of the first centers that did it, and reported it, and became a pioneer in that field.
Catherine: Can you explain how ECMO technology is used for lung transplantation?
Dr. Arcasoy: This is a tool that is used for extremely sick patients who are unable to exchange oxygen and carbon dioxide using, non invasive methods as well as mechanical ventilation using a breathing tube. And it entails using relatively large intravenous or arterial cannulas to circulate blood through an oxygenator to, put oxygen into the blood to circulate into the body and remove carbon dioxide.
And when we started doing this, we were using special upper extremity cannulas to, to achieve what I mentioned, and then have patients walk with the machine without being on the ventilator, [08:00] without being sedated, able to eat and communicate. And then basically after that, the field evolved significantly. You know, many centers in the world and in the U. S. now apply this technology but this is something that we feel very proud of because we did a large number of transplants using ECMO Bridge to, to transplant.
Catherine: Hm and that must be amazing in terms of the patients well being - to be able to function to some degree.
Dr. Arcasoy: Absolutely, yeah absolutely.
Catherine: Um, so I wanted to talk to you more about the procurement and the allocation system, because I understand there were changes between 2005 and 2023. and I know you were running through the list of what the final rules were asking the system to accomplish in terms of how to rank patients and how to weigh different variables, but I know you were touching on the geography problem. So, can you tell me more about that because it doesn't sound from where you just said that the original LAS, the lung allocation score, took into account geography.
Dr. Arcasoy: Yes, the U. S. [09:00] is divided into 58 donation service areas, and they are areas of different size, different population, some extremely populated, others, not so dense, some tiny like the New York area, some extremely large like around Texas or California, so very, very variable. Very variable number of donors available in each area. And unfortunately, New York was one of the worst performing areas in terms of donor availability. The way the organ allocation system worked, whether it was wait list time based or lung allocation score based, was the fact that organ allocation occurred primarily in that region, and then only went out to other regions if lung transplant centers declined those organs in that region.
Catherine: Oh, so it kind of was like a first dib [10:00] system where you'd have first dibs on lungs in your area and only if no one in that area used them where they become available elsewhere.
Dr. Arcasoy: Exactly. And so, a good example that's easy to kind of visualize here is the Hudson River between us and New Jersey. So, if we have a patient in the medical ICU on ECMO bridge to transplant with a lung allocation score of 90, 0 to 100, 90 being really sick, that person would not get any offers from New Jersey in the old system. Because New Jersey was a different region, although it's a mile across from us.
Catherine: Right, and you might be able to even see it.
Dr. Arcasoy: Yes, I actually see New Jersey from my office, and it was a system that was maddening, and, we have published articles, we've written to UNOS. We, we wrote a letter, actually a formal letter to the thoracic committee. to alter the system for sick people. [11:00] For example, we proposed patients with lung allocation score greater than 50 should not be bound by the primary allocation region.
So, we identified high donor availability areas and low donor availability areas. And we show that if you're listed in a low donor lung availability area, you have a much lower rate of transplant and much higher wait list mortality. In 2017 One of our patients, a young woman who was extremely sick with pulmonary hypertension, was in our ICU on, central veno arterial ECMO.
And she had an unusual blood type, so she was basically waiting for lungs that would be available in our area, in our donation service area. So she basically filed a lawsuit asking for broader access to organs so that she could survive. And, the lawsuit [12:00] was filed, on Monday of Thanksgiving week in 2017. And there were emergency meetings. And by Friday of the same week, on Black Friday, the system was changed to expand it from donation service area to 250 mile circle, which basically broadened access to, to lungs, in areas like us, that are small. It really made a big impact for our patients when that happened.
Catherine: Did that lawsuit call upon any of your research?
Dr. Arcasoy: It did, yes, but I think the lesson to learn there is lawsuits are more effective than research.
Catherine: I was hoping that wouldn't be the takeaway.
Dr. Arcasoy: Egan, who's the architect of the lung allocation system, wrote an editorial about this, saying something like, from so many number of years to five days, how the system changed within five days. And [13:00] that really allowed us to transplant patients faster, although it did not solve the problem. And we did publish a subsequent paper two years later, looking at before and after the 250 mile change in 2017. And it seemed like things did get better but disparities still persisted based on geography.
Catherine: I mean, going back to the lawsuit, do you think it'd be fair to say the lawsuit would not have been as effective if they didn't have any research to back it up?
Dr. Arcasoy: I would think so. Yes. I think our publication record was, really very robust, in showing problems with the geographic cliffs, so to speak. So I think the research certainly must have helped make the decision back in the day.
Catherine: Gotcha, So you had mentioned that there has been a significant increase in transplants. How has that increase impacted survival rates for the lung transplant program?
Dr. Arcasoy: In our first decade [14:00] here, our survival was stellar and it's still stellar, but it is affected by the patient population for sure. So our one year survival is about 90%, and it's only one or two percentage points, lower now, about 88, 89%. Five year survival was 68%, now maybe 65, 64%, and 10 year survival was 45 percent and now it's about 40%.
And why is it lower? It's lower because we're taking on much sicker patients. We're also transplanting patients in their 70s with numerous comorbid illnesses. So they not only have lung failure, they have vascular disease, diabetes, sometimes coronary disease that requires stenting before transplant, or [15:00] concomitant bypass surgery, some kidney dysfunction, and, and so on.
So I think the patient population is different, plus they're sicker at time of transplant. And that's indicated by the benchmark reports that show how high their lung allocation score was at the time of listing and at time of transplant. So the volume is unbelievable. I mean, we've done, since I started over 1400, lung or heart lung transplants, and a couple of other multi-organ like lung, liver, kidney, or lung liver or lung kidney transplants.
So we do a few of those each year as well. And Columbia transplant volume has exceeded 1,600 transplants since its inception, so there's a lot of experience here and this is what I tell referring doctors, patients, and families. If they contact us that, yeah, there are a lot of new programs around, but if you really want the [16:00] years of experience, cohesive teamwork, program dedication, dedication of the hospital and the university to the well being of patients. I think this is the place to come to with also cutting edge research and opportunity to participate in that as well.
Catherine: So let's talk about some of that research. I understand you’re doing work aimed to increase transplant success rates and survival times. Tell me about that.
Dr. Arcasoy: We investigate different diagnostic markers to diagnose rejection sooner, whether it be cell free DNA, analysis in blood samples, or, looking at molecular genetic signatures in blood or lung samples. And the question is whether you could alleviate the need for doing lung biopsies after transplant, which is now common practice, to look for rejection.
Imagine you're taking 10 or 15 cuticle [17:00] sized biopsies from a lung. A good analogy is looking for mold in a haystack. If you pull 10 or 15 strands of hay and look for mold, you may easily miss it. So the same thing applies in lung. If, if you have not biopsied the right areas, you may miss rejection, yet patients may have rejection that is not obvious under the microscope.
So how can we identify it better is the question. We actually, Collaborate with Columbia Center for Translational Immunology. And one of the principal investigators there is, trying to develop an immunologic, tool set, or toolbox, looking at immunologic switch in the blood and Lungs, transplanted lungs from donor to recipient and whether or not that could predict the development of rejection. I think [18:00] ideally we'll use multiple tools to try to identify and then treat rejection sooner so it does not lead to chronic lung allograft dysfunction in the future.
Catherine: That seems like a really strong reason to seek out a transplant at NewYork-Presbyterian.
Dr. Arcasoy: I mean, there's a lot of research opportunity here and we try to identify and understand common problems that we all encounter. In the country or in the world, to understand the pathophysiology of why things happen and then figure out and generate hypotheses as to how we could prevent them.
Catherine: That's wonderful how you're taking such a holistic approach to treating lung transplant patients. So, you know, thank you so much for the work that you're doing and also thank you for joining me today.
Dr. Arcasoy: My pleasure. Thank you for giving me the chance.
Huge thanks to Dr. Selim Arcasoy for taking the time to talk about how the Lung Transplant Program at NewYork-Presbyterian [19:00] / Columbia is continuing to innovate and improve lung transplant access and success.
I’m Catherine Price.
Advances in Care is a production of NewYork-Presbyterian Hospital. As a reminder, the views shared on this podcast solely reflect the expertise and experience of our guests. To listen to more episodes of Advances in Care, be sure to follow and subscribe on Apple Podcasts, Spotify, or wherever you get your podcasts. And to learn more about the latest medical innovations from the pioneering physicians at New York Presbyterian, go to nyp.org/advances.
[19:40]