Transforming Lung Transplantation: Insights from a Toronto Fellowship

Excellence in Lung Transplantation

A surgical fellowship in lung transplantation at the Ajmera transplant center in Toronto General Hospital (TGH), home to the largest and most active lung transplantation program in the world, is all-encompassing. For anyone interested in thoracic transplantation, it is a transformative experience. The learning extends far beyond surgical exposure. What stands out is the seamless integration of fearless clinical innovation, rigorous outcomes-driven practice, and a deeply embedded culture of research and training.

TGH performs more than 200 lung transplants each year. Since the program’s inception with the world’s first lung transplant success in 1983,over 3,500 transplants have been carried out with a median 30-day mortality of2.4% over the past 10 years. Central to this success is a bold and pragmatic philosophy: if a donor lung has any potential, it is given every opportunity to be used. Marginal donor lungs are routinely procured, put through thorough assessment and rehabilitation, and, where appropriate, are transplanted. This approach is enabled by the prolific use of Ex Vivo Lung Perfusion (EVLP), a technology that TGH pioneered, and which was a major driver for choosing to carry out my fellowship here.

The Challenges and Reasoning

I applied for the fellowship to help support my plan to attend this high-volume center of excellence in lung transplantation in order to gain exposure to a range of complexities, benefit from the assessment process and listing of high-risk lung transplant recipients, as well as the evaluation of marginal donor offers and their optimization with EVLP whenever necessary.

My ultimate goal is to take these learned skills back to the UK and help improve the state of lung transplantation.

Lung transplantation numbers in the UK have been consistently low, averaging below 50% of the waiting list pool over the past 10 years, and have struggled to return to pre-pandemic levels. National activity levels, which were modest at a height of 214 just before the COVID-19 pandemic, have averaged only about 120 per year nationally over the past 5 years. According to the most recent NHSBT data, of the 1,880 consented organ donors last year, only 7% were deemed suitable for lung transplantation compared to 13% for heart and 45% for liver transplantation. Furthermore, of the consented lung donors meeting age criteria, only 15% of donors after brain death (DBD) and 5% of donors after circulatory death (DCD) were accepted for transplantation. These low transplant numbers has meant that about 60% of non-urgent lung transplant recipients are either still waiting, have been removed from the waiting list, or are dead at 3 years post-registration. About 12-15% of patients die on the UK lung transplant waiting list each year.

The reasons for the low rates of potential donors progressing to lung transplantation in the UK are multifactorial: limited ICU and theatre capacity, logistical delays, stricter recipient listings (e.g. age criteria), cautious donor selection, and marginal organs often being turned down, not due to clinical incompetence but because the EVLP technology available to support their evaluation and  optimization isn’t routinely  utilized due predominantly to a lack of expertise. I hope to be able to contribute to addressing these issues.

Impact and Future Vision

I had an incredible time in Toronto and achieved all my goals and objectives. I operated on about 70 lung transplants, gained competence in the use of EVLP, and the insertion and management of extracorporeal membrane oxygenation (ECMO) needed for critically ill patients. I gained confidence in the assessment and listing of higher risk transplant recipients, and the evaluation of marginal donor lung offers. These achievements are due to the expertise of the surgeons I worked with whose dedication to teaching is second to none, including Dr. Jonathan Yeung, Dr. Thomas Waddell, Dr. Kazuhiro Yasufuku, Dr. Laura Donohoe, Dr. Marcelo Cypel, and Dr. Shaf Keshavjee. It was an immense privilege to work and benefit from their wealth of experience in all aspects of lung transplantation.

My lung transplant surgical fellowship at Toronto General Hospital has been transformational for my career as a cardiac surgeon specialized in heart and lung transplantation. The exposure to the successful perioperative management of higher risk lung transplant recipient profiles, and the evaluation,  optimization (with the aid of EVLP), and successful  utilizations of marginal donor lungs that would otherwise have been declined for transplant, has afforded me the confidence, knowledge, and skillset to bring these into my clinical practice as a consultant and help improve the state of lung transplantation in the UK.

The Levi Watkins Innovation and Leadership Development Scholarship from the Thoracic Surgery Foundation helped make this invaluable career progression possible and for this, I am truly thankful.

Words of Advice

The lung transplant surgical fellowship at Toronto General Hospital is a highly rewarding program but also very competitive to acquire. My advice to any aspiring lung transplant surgeon thinking about this fellowship is to plan well in advance and build a CV that clearly displays your clinical acumen and commitment to lung transplantation.

I am very grateful for being awarded the 2025 Levi Watkins Innovation and Leadership Development Scholarship which helped me immensely in pursuing my goal of carrying out a lung transplant surgical fellowship at Toronto General Hospital.