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Outcomes of Heart Transplantation From COVID-19 Donors
Quick Takes
- Heart transplant recipients of active COVID-19 donors (NAT-positive prior to organ procurement) had a higher adjusted hazard for mortality at 6 months and at 1 year compared with non–COVID-19 donors.
- Heart transplant recipients of recently recovered COVID-19 donors (NAT-positive during terminal hospitalization but negative prior to organ procurement) had similar outcomes compared with non–COVID-19 donors.
- Rates of heart transplant from COVID-19 infected donors are increasing.
Study Questions:
What are the donor/recipient characteristics and outcomes of heart transplantation (HT) using coronavirus disease 2019 (COVID-19) infected donors in the United States?
Methods:
This study used the United Network for Organ Sharing (UNOS) database and included donors between May 2020 and June 2022 with information on organ disposition and COVID-19 nucleic acid testing (NAT) status. Donors who were NAT-positive at any time during their terminal hospitalization were considered COVID-19 donors. They were further classified as active COVID-19 donors if they were NAT-positive within 2 days of organ procurement or if their last NAT test was positive >2 days prior to procurement with no additional testing. Recently resolved COVID-19 donors were donors who were initially NAT-positive but became NAT-negative prior to organ procurement. Primary outcomes included all-cause mortality at 6 months and 1 year.
Results:
Overall, 27,862 donors were included, and 1,445 donors had ≥1 COVID-19 NAT-positive test. The study included 238 adults with HT performed with COVID-19 donors (150 with active COVID-19 and 89 from recently recovered donors). HT recipients from COVID-19 donors were more likely to be blood type O. The number of COVID-19 donor HTs increased during the study period and peaks for HT with COVID-19 donors followed surges in community-reported COVID-19 rates. Compared to non–COVID-19 donors, COVID-19 donors were younger, male, and more likely to have head trauma with other characteristics including left ventricular ejection fraction being similar.
HT with active COVID-19 donors had a higher adjusted hazard for mortality at 6 months compared with non–COVID-19 donors (hazard ratio [HR], 1.81; 95% confidence interval [CI], 1.07-3.11) and at 1 year (HR, 2.10; 95% CI, 1.29-3.42). HT with recently recovered COVID-19 donors had no statistically significant difference in 6-month and 1-year survival. These results persisted in propensity-matched analyses. There was no significant difference in the risk for in-hospital stroke, dialysis, pacemaker insertion, and post–heart failure (HF) length of stay between COVID-19 donors and non–COVID-19 donors.
Conclusions:
In a study from the UNOS database, the authors noted an increasing use of COVID-19 donors who tended to be younger males. HT recipients from active COVID-19 donors had a higher risk for 6-month and 1-year mortality post-transplant compared to non–COVID-19 donors. This risk was not noted for HT recipients of recently recovered COVID-19 users.
Perspective:
The COVID-19 pandemic has adversely impacted all facets of care for HF patients. This holds particularly true for patients with end-stage HF listed for HT as several programs paused transplants during the pandemic. With decreasing mortality associated with COVID-19 infections, programs have resumed transplantation. However, community prevalence of subclinical COVID-19 infection has increased, and hence, donors are more likely to test positive in the absence of clinical infection. Given scarcity of donors, whether organs from COVID-19 infected donors should be used poses a clinical dilemma.
This study provides interesting insights into outcomes with COVID-19–positive donors. The study suggests increased 6-month and 1-year mortality in HT recipients of organs from actively infected COVID-19 donors, whereas outcomes in HT recipients from recently recovered COVID-19 donors were no different. These results persisted with propensity-matched analyses and, notably, organs from COVID-19 donors had a more favorable clinical profile. Despite lack of evidence on safety of HT from COVID-19–infected donors, the study shows an increase in use of such organs. While the study lacks data on nuances that may impact outcomes associated with HT from COVID-19 donors such as vaccination status for donor and recipients, treatments received by donors, or markers of virus activity (such as cycle threshold), these results suggest avoiding HT from actively infected COVID-19 donors.
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, Acute Heart Failure, Heart Transplant
Keywords: Cardiac Surgical Procedures, COVID-19, COVID-19 Nucleic Acid Testing, COVID-19 Testing, Heart Failure, Heart Transplantation, Length of Stay, Pacemaker, Artificial, Renal Dialysis, Secondary Prevention, Stroke, Transplant Recipients, Ventricular Function, Left
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