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Characteristics and Outcomes of Recipients of Heart Transplant With Coronavirus Disease 2019

Educational Objective
To understand the risk of COVID-19 infection for the recipients of heart transplant
1 Credit CME
Key Points

Question  What are the characteristics and outcomes of patients with heart transplant who are infected with coronavirus disease 2019 (COVID-19)?

Findings  In this case series of 28 patients who had received heart transplant in a large academic center, the case fatality rate among patients infected with COVID-19 was 25%. Cardiovascular comorbidities were frequent in this population, and immunosuppressive therapy was reduced in most patients.

Meaning  Recipients of heart transplant are at high risk for severe complications from coronavirus disease 2019 infection; management of this population is complex and should take place in a transplant center.

Abstract

Importance  Recipients of heart transplant (HT) may be at increased risk of adverse outcomes attributable to infection with coronavirus disease 2019 (COVID-19) because of multiple comorbidities and clinically significant immunosuppression.

Objective  To describe the characteristics, treatment, and outcomes of recipients of HT with COVID-19.

Design, Setting, and Participants  This case series from a single large academic heart transplant program in New York, New York, incorporates data from between March 1, 2020, and April 24, 2020. All recipients of HT followed up by this center who were infected with COVID-19 were included.

Interventions  Heart transplant and a confirmed diagnosis of COVID-19.

Main Outcomes and Measures  The primary measure was vital status at end of study follow-up. Secondary measures included patient characteristics, laboratory analyses, changes to immunosuppression, and treatment administered for COVID-19.

Results  Twenty-eight patients with HT received a confirmed diagnosis of COVID-19. The median age was 64.0 (interquartile range [IQR], 53.5-70.5) years, 22 (79%) were men, and the median time from HT was 8.6 (IQR, 4.2-14.5) years. Comorbid conditions included hypertension in 20 patients (71%), diabetes in 17 patients (61%), and cardiac allograft vasculopathy in 16 patients (57%). Twenty-two participants (79%) were admitted for treatment, and 7 (25%) required mechanical ventilation. Most (13 of 17 [76%]) had evidence of myocardial injury (median high-sensitivity troponin T, 0.055 [IQR, 0.0205-0.1345] ng/mL) and elevated inflammatory biomarkers (median peak high-sensitivity C-reactive protein, 11.83 [IQR, 7.44-19.26] mg/dL; median peak interleukin 6, 105 [IQR, 38-296] pg/mL). Among patients managed at the study institution, mycophenolate mofetil was discontinued in 16 patients (70%), and 6 (26%) had a reduction in the dose of their calcineurin inhibitor. Treatment of COVID-19 included hydroxychloroquine (18 patients [78%]), high-dose corticosteroids (8 patients [47%]), and interleukin 6 receptor antagonists (6 patients [26%]). Overall, 7 patients (25%) died. Among 22 patients (79%) who were admitted, 11 (50%) were discharged home, 4 (18%) remain hospitalized at the end of the study, and 7 (32%) died during hospitalization.

Conclusions and Relevance  In this single-center case series, COVID-19 infection was associated with a case fatality rate of 25% in recipients of HT. Immunosuppression was reduced in most of this group of patients. Further study is required to evaluate the optimal approach to management of COVID-19 infection in the HT population.

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Article Information

Accepted for Publication: May 1, 2020.

Corresponding Author: Nir Uriel, MD, MSc, Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, Weill Cornell Medicine, 622 W 168th St, PH 4-129, New York, NY 10032 (nu2126@cumc.columbia.edu).

Published Online: May 13, 2020. doi:10.1001/jamacardio.2020.2159

Author Contributions: Drs Uriel and Clerkin had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Latif and Farr had an equal contribution to the manuscript.

Concept and design: Latif, Farr, Clerkin, Habal, Naka, Sayer, Uriel.

Acquisition, analysis, or interpretation of data: Latif, Farr, Clerkin, Habal, Takeda, Restaino, Uriel.

Drafting of the manuscript: Farr, Clerkin, Naka, Restaino, Sayer, Uriel.

Critical revision of the manuscript for important intellectual content: Latif, Farr, Clerkin, Habal, Takeda, Naka, Sayer, Uriel.

Statistical analysis: Clerkin, Uriel.

Administrative, technical, or material support: Clerkin.

Supervision: Latif, Sayer, Uriel.

Conflict of Interest Disclosures: Dr Naka reported personal fees from Abbott, CryoLife, and Zimmer-Biomet outside the submitted work. No other disclosures were reported.

Funding/Support: Dr Clerkin is supported by the National Heart, Lung, and Blood Institute (grant K23HL148528).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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