How Do Heart Transplant Recipients Fare During the COVID-19 Pandemic?

The worldwide fatality rate from coronavirus disease 2019 (COVID-19) now exceeds 7%, and more than 3 million cases have been reported. New York, New York, alone has a fatality rate above 7%, as of April 26, 2020.

A team of physicians from a large academic medical center in New York, New York, recently reviewed the treatments and outcomes of heart transplant recipients with COVID-19 in order to better understand how to treat this delicate population during the pandemic. JAMA Cardiology published their results online last week.

Cardiovascular disease is a well-known factor for increasing the risk of contracting this sometimes deadly virus. The risk is compounded even more among patients with heart failure who receive a transplanted heart due to a possible higher risk of infection and comorbidities that include hypertension, diabetes, and cardiac allograft vasculopathy.

Data on 28 patients, collected between March 1 and April 24, 2020, were analyzed for the primary measure of vital status at follow-up conclusion. All were at least 18 years old, the median (interquartile range [IQR]) age was 64 (53.5-70.5) years, and the median (IQR) time between transplant and positive COVID-19 test result was 8.6 (4.2-14.5) years.

Overall, 25% of these patients died. Hypertension, diabetes, and cardiac allograft vasculopathy appeared in 71%, 61%, and 57%, respectively. Other common comorbidities included obese (body mass index > 30 kg/m²) status in 28%; stage IV or greater chronic kidney disease in 36%, with 18% on hemodialysis; and preexisting allograft dysfunction in 14%. In addition, 79% required hospital admission for COVID-19, of whom 25% needed ventilation in the intensive care unit, 21% were treated as outpatients, and 32% died. None, however, exhibited signs of organ rejection.

Results from lab values measured included a median (IQR) white blood cell count of 4.9 x 10⁹/L (3-8.9 x 10⁹/L) and a median (IQR) lymphocyte count of 0.6 x 10⁹/L (0.3-0.8x 10⁹/L). Cardiac injury was indicated by a median (IQR) peak high-sensitivity troponin T level of 0.055 (0.0205-0.1345) ng/mL. Plus, inflammation values “were markedly elevated” in all patients, as shown by a median (IQR) high-sensitivity C-reactive protein of 11.83 (7.44-19.26) mg/dL; elevated IL-6 in 88%, with a median (IQR) peak of 105 (38-296) pg/mL; and D-dimer levels in 8/2% above 1 μg/mL.

“Managing recipients of [heart transplant] with COVID-19 has increased complexity because they have more intense immunosuppression than many other solid organ transplant recipients, combined with the potential for the virus to cause both primary and secondary myocardial injury,” the authors concluded. “Although our cohort is small, we recommend that patients who have received [heart transplant] are treated at a transplant center while infected with COVID-19.”

They propose caution when interpreting their results because of the small sample size, lack of testing among asymptomatic patients, and inability to differentiate which among cardiovascular risk factors, immunosuppression, or having undergone the transplant increased the mortality rate. Additional randomized clinical studies of this patient population are proposed so that physicians and support personal can learn how to best manage these delicate cases.

Reference

Latif F, Farr MA, Clerkin KJ, et al. Characteristics and outcomes of recipients of heart transplant with coronavirus disease 2019. JAMA Cardiol. Published online May 13, 2020. doi:10.1001/jamacardio.2020.2159