Heart Transplant Outcomes Similar With COVID-19–Positive Donors

Marilynn Larkin

November 03, 2022

Patients who receive hearts from COVID-19–positive donors will likely have short-term outcomes similar to those who receive hearts from COVID-19–negative donors, two retrospective analyses suggest.

COVID-19 rarely causes cardiac injury among young, healthy people; however, endothelial dysfunction and subcellular derangements might have longer-term consequences for a mild or subclinical infection in the transplanted organ, according to Clancy Mullan, MD, and colleagues at the Yale School of Medicine in New Haven, Connecticut. Therefore, the team investigated outcomes of patients in the United Network for Organ Sharing (UNOS) database who received hearts from COVID-19–positive donors.

"I was personally surprised to find so many SARS-CoV-2–positive donors referred," Mullan told the heart.org | Medscape Cardiology. "We found 280 SARS-CoV-2–positive donor referrals with seemingly acceptable hearts, which suggests that the limiting step to utilization is at the acceptance phase, rather than referral phase of organ recovery."

Rates of 30-day and 1-year survival were 100% among those receiving hearts from SARS-CoV-2–positive donors in the study, which was published online October 12 in the Journal of the American College of Cardiology: Heart Failure.

Similar findings from a separate UNOS analysis were released October 31 and will be presented at the American Heart Association (AHA) Scientific Sessions 2022 by Samuel T. Kim, MD, of the David Geffen School of Medicine at the University of California, Los Angeles.

Positive Findings

Mullan and colleagues compared survival data from March 2020 to December 2021 from 32 of 37 recipients of hearts from SARS-CoV-2–positive donors and 5445 recipients of allografts from SARS-CoV-2–negative donors.

Of note, 243 hearts from SARS-CoV-2–positive donors were declined. Accepted organs came from donors who were younger (median age, 28 vs 47 years), less likely to be women (8.1% vs 39.1%), and with a lower body mass index (27.0 vs 31.6 kg/m2). Accepted hearts had a higher ejection fraction (median, 64% vs 60%) and were less likely to be donated after circulatory death (8.1% vs 56.4%).

Demographics, comorbidities, urgency status at transplantation, blood type, and pretransplantation support were similar among recipients of hearts from COVID-19–positive and –negative donors.

All recipients of hearts from COVID-19–positive donors were alive at 30 days and at 1-year follow-up.

The main limitation of the UNOS dataset for this kind of analysis is the lack of COVID-19 symptomatology of the donors or the temporal relationship of infection to organ retrieval, the authors write.

Mullan noted, "The current Organ Procurement and Transplantation Network recommendations include an analysis of multiple solid organs from SRTR (a different organ transplantation database), which had similar findings to ours, particularly in regard to heart utilization.

"COVID is going to be with us for a long time, and this is an important question that certainly doesn't have a complete answer now and may never have a perfect answer," he said. "We should continue to investigate this and consider otherwise acceptable organs in the context of a risk-benefit discussion with our recipients and their families."

The study presented by Kim and colleagues, which was also a UNOS analysis, included 3289 heart transplants performed between February 2021 and March 2022. Eighty-four of the hearts were from COVID-19–positive donors. Cold ischemic times for these hearts were similar to those of hearts from nonpositive donors (3.7 vs 3.5 hours).

Overall, lengths of stay were similar for both groups of recipients (15 days for COVID-19–positive vs 17 days for COVID-19–negative), as were rates of graft failure (2.4% vs 1.0%), postoperative stroke (0.0% vs 3.0%), postoperative dialysis (15.5% vs 13.4%), and 30-day posttransplant survival (96.1% vs 97.0%).

None of the four deceased recipients of COVID-19–positive allografts died from pulmonary or infectious causes.

Long-term Follow-Up "Imperative"

Anuradha Lala, MD, an advanced heart failure and transplant cardiologist at the Mount Sinai Hospital in New York City, commented on the findings for theheart.org | Medscape Cardiology.

"Various effects of COVID-19 on the cardiovascular system have been reported to date, including thrombosis, inflammation, endothelial dysfunction, and, rarely, myocarditis and incident heart failure," Lala said. "Therefore, whether to utilize SARS-CoV-2 donor hearts for patients awaiting heart transplantation has been a challenging dilemma, leading to varying practices across the United States."

The findings provide "some reassurance" regarding short-term safety, she said. However, "detailed information as to the incremental impact of SARS-CoV-2 on donors requires further inquiry. For example, how symptomatic were donors? What was the extent of disease burden? What was the duration of active disease in relation to time of transplantation?

"As vaccination is more ubiquitous and disease burden attributed to SARS-CoV-2 is less onerous than earlier in the pandemic, more and more centers are comfortable utilizing SARS-CoV-2–positive donor hearts, as risk of dying on the transplant waiting list needs to be weighed carefully against a more theoretical risk of complication attributed to COVID," she said. "Tracking long-term outcomes for these patients will be imperative for our community and patients, as we humbly continue to learn more about sequelae on the cardiovascular system and otherwise."

No commercial funding or relevant conflicts of interested were disclosed for the study or presentation.

JACC Heart Fail. Published online October 12, 2022. Abstract

American Heart Association (AHA) Scientific Sessions 2022: Abstract 563. To be presented November 6, 2022.

Follow Marilynn Larkin on Twitter: @MarilynnL.

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