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COVID-19 in Heart Transplant Recipients
Quick Takes
- In a cohort of 28 heart transplant recipients with COVID-19 infection, the mortality rate was high, at 25%.
- Changes in immunosuppression were made for most, but there was no overt graft rejection noted in the short-term.
Study Questions:
What are clinical characteristics and outcomes of heart transplant recipients on chronic immunosuppression who develop coronavirus disease 2019 (COVID-19) infection?
Methods:
This is a case series of all adult heart transplant recipients at a large tertiary care center who tested positive for COVID-19 infection. Laboratory and treatment data were collected for all of these patients managed as outpatients or as inpatients.
Results:
In a cohort of 803 heart transplant recipients, over 6 weeks, 28 patients presented for acute care for COVID-19 infection: six were treated as outpatients. Median age was 64 years, 79% were men, and median time from transplant was 8.6 years. Comorbidity burden was high: 71% had hypertension, 61% had diabetes, 25% were obese, and 36% had chronic kidney disease stage 4 or worse. The vast majority presented with fever, dyspnea, or cough. However, 48% had gastrointestinal symptoms.
Among those hospitalized, incidence of myocardial injury defined as an elevated troponin level was seen in 77%. Supplemental oxygen was needed in 20 out of the 22 hospitalized patients, seven needed mechanical ventilation, and three needed dialysis. Therapy for COVID-19 infection was administered to 23 patients (eight received high-dose steroids, 18 received hydroxychloroquine, and six received interleukin-6 antagonist). Changes in immunosuppression made were discontinuation of cellcept (70%) and calcineurin inhibitor dose reduction (26%). None of the patients experienced overt graft rejection. Mortality rate was 25%.
Conclusions:
In a case series of 28 heart transplant recipients with COVID-19 infection, the mortality rate was high, at 25%. Not all patients needed hospitalization, and six patients out of 22 were treated as outpatients. Changes in immunosuppression were commonly made, but overt graft rejection was not seen over the short-term.
Perspective:
Managing heart transplant recipients with COVID-19 infection is challenging due to need for immunosuppression that likely leads to an increased risk for the infection itself and for complications from the infection. As expected, the mortality rate in this cohort of 28 heart transplant recipients was high. A significant proportion presented with gastrointestinal symptoms. Nearly one-third needed mechanical ventilation. While this case series provides early insights into clinical characteristics of the infection, managing these patients remains challenging. Notably, the majority of the patients had reduced doses of immunosuppressive therapy, but overt graft rejection was not seen over the short-term.
Clinical Topics: Cardiac Surgery, COVID-19 Hub, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Novel Agents, Statins, Acute Heart Failure, Heart Transplant, Hypertension
Keywords: COVID-19, Coronavirus, Diabetes Mellitus, Dyspnea, Graft Rejection, Heart Failure, Heart Transplantation, Hydroxychloroquine, Hypertension, Immunosuppression, Inpatients, Outpatients, Obesity, Renal Insufficiency, Chronic, Renal Dialysis, Respiration, Artificial, Secondary Prevention, severe acute respiratory syndrome coronavirus 2, Troponin
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