COVID-19 Case Fatality Doubled in Heart Transplant Patients

Debra L. Beck

December 18, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Heart transplant recipients infected with SARS-CoV-2 are about twice as likely to die from COVID-19 and should be immediately referred to a transplant center for care, according to transplant experts from Northern Italy.

In a COVID Rapid Report published December 9 in JACC Heart Failure, a group led by Tomaso Bottio, MD, PhD, from the University of Padua, Padua, Italy, presents findings on 47 heart transplant recipients who tested positive for SARS-Cov-2 between February 21 and June 30.

The investigators found a case fatality rate of 29.7% compared with 15.4% in the general population. Prevalence of infection was also much higher at 18 cases (vs. 7) per 1000 population.

"In our opinion, prompt referral to a heart transplant center is crucial for immunosuppressive therapy optimization and cardiologic follow-up," Bottio wrote in an email exchange with | Medscape Cardiology.

Beyond the need for careful adjustment of immunosuppression, graft function should be assessed to "avoid acute rejection or decompensation," he added.

Bottio and colleagues tracked COVID-19 cases from among the 2676 heart transplant recipients alive before the onset of the pandemic at seven heart transplant centers in Northern Italy.

Of the 47 recipients who contracted SARS-CoV-2, 38 required hospitalization while 9 remained at home and 14 died. Mean length of stay in hospital was 17.8 days, much longer in survivors than nonsurvivors (23.2 days vs 8.5 days; P < .001).  

Nonsurvivors were significantly older than survivors (72 vs 58 years; P = .002). Nonsurvivors were also more likely to present with diabetes (P = .04), extra-cardiac arteriopathy (P = .04), previous percutaneous coronary intervention (P = .04), more allograft vasculopathy (P = .04) and more symptoms of heart failure (P = .02).

Although the authors said the high case fatality rate was, unfortunately, expected, they did not expect so many patients to do well at home.

"What most surprised us was the proportion of a- or pauci-symptomatic heart transplanted patients who did well being treated at home without any therapy modifications," Bottio shared. They were also surprised to see there were no cases of graft failure due to infection-related myocarditis.

These findings from Northern Italy are not dissimilar from the 25% case fatality rate seen in a cohort of heart transplant recipients who caught COVID-19 in New York City early in the pandemic.

In another study, this time looking at a wider group of solid organ transplant recipients with SARS-CoV-2 infection at two centers during the first 3 weeks of the outbreak in New York City, 16 of 90 patients (18%) died.

Treatment Recommendations?

Recognizing that there is no randomized trial data informing the treatment of this vulnerable patient population, Bottio and colleagues suggested that, based on their experience, no change in immunosuppression is needed in those who are "pauci-symptomatic" (mildly symptomatic).

"On the other hand, in hospitalized patients a partial reduction in immunosuppressive therapy avoiding full discontinuation and risk of graft rejection seems to be a common strategy in facing the viral infection," he said. "In addition, the introduction of corticosteroids could help to suspend the onset of the inflammatory cascade responsible for severe forms of the disease."

Antibiotic prophylaxis appears to be "fundamental," he added, particularly in hospitalized patients, but "the role of specific antiviral therapies is still not fully understood in our population."

Since July 1, they've seen an additional 6 patients with a positive test for SARS-CoV-2. Five were asymptomatic and quarantined at home without changing their immunosuppressive therapy. One patient was hospitalized for pneumonia and had immunosuppressive therapy reduced.

Bottio and the study coauthors have disclosed no relevant financial relationships.

J Am Coll Cardiol. Published online December 9, 2020. Full text

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