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Expanding Heart Transplant in the Era of Antiviral Therapy for Hepatitis C
Study Questions:
What is the association of hepatitis C–positive donors with heart transplant volumes, wait-list duration, the transmission and cure of donor-derived hepatitis C, and morbidity and mortality at 1 year?
Methods:
The investigators conducted a prospective, single-center observational study of 80 adult (aged ≥18 years) patients who underwent heart transplant using hearts from hepatitis C–positive donors between September 2016 and April 2019 at a large academic medical center. Among donors, who were considered hepatitis C–positive if results from hepatitis C antibody and/or nucleic acid testing were positive, 70 had viremia and 10 were seropositive but did not have viremia. Follow-up was available through May 15, 2019. Comparisons were drawn with patients who underwent transplant with hearts from hepatitis C–negative donors during the same period. In addition to standard post-transplant management, transplant recipients who developed donor-derived hepatitis C infection were treated with direct-acting antivirals. The main outcomes included wait-list duration and 1-year survival in all patients, and for those who developed donor-derived hepatitis C, the response to direct-acting antiviral treatment.
Results:
Of 80 patients, 57 (71.3%) were men, 55 (68.7%) were white, and 17 (26.3%) were black; the median age at transplant was 54.5 years (interquartile range, 46-62 years). Following consent to accept hearts from hepatitis C-exposed donors, the median days to heart transplant was 4 (interquartile range, 1-18). No recipients of donors with negative nucleic acid testing results (10 [12.5%]) developed donor-derived hepatitis C. Of 70 patients who were recipients of donors with positive nucleic acid testing results, 67 (95.7%) developed donor-derived hepatitis C over a median follow-up of 301 days (interquartile range, 142-617). Treatment with direct-acting antivirals was well tolerated and yielded sustained virologic responses in all treated patients. Within the cohort with infection, 1-year patient survival was 90.4%, which was not significantly different compared with the cohort without infection or with patients who received transplants from hepatitis C–negative donors during the same period.
Conclusions:
The authors concluded that in the era of direct-acting antivirals, hepatitis C–positive donors are a viable option to expand the donor pool, potentially reducing wait-list duration and mortality.
Perspective:
This case study reports that donor-derived hepatitis C infection after heart transplant was easily curable with direct-acting antivirals despite immunosuppression, and 1-year survival, which exceeded 90%, was not significantly different when compared with survival among patients who were transplanted with hearts from hepatitis C–negative donors during the same period. These data suggest that using hepatitis C–positive donors may substantially expand the donor pool for patients awaiting heart transplant, increase transplant volumes, and reduce morbidity and mortality on the wait-list. Additional prospective studies are indicated to assess longer-term outcomes, specifically coronary allograft vasculopathy, to guide the optimal timing and duration of hepatitis C virus therapy and better apprise wait-listed patients and clinicians regarding this option.
Clinical Topics: Cardiac Surgery, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant
Keywords: Allografts, Antiviral Agents, Cardiac Surgical Procedures, Heart Failure, Heart Transplantation, Hepacivirus, Hepatitis C, Hepatitis C Antibodies, Nucleic Acids, Secondary Prevention, Tissue Donors, Viremia
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