Small series points to complex issues for HT patients with Covid-19

Over an 8-week period beginning March 1, doctors at a large academic medical center in New York confirmed SARS-CoV-2 infection in 28 heart transplant patients, and seven of those patients died from Covid-19.

“Of note, we did not routinely test patients who were asymptomatic, and there were limitations on testing patients with mild symptoms at the earliest phases of the pandemic,” wrote Farhana Latif, MD Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons and colleagues in JAMA Cardiology. “Therefore, we may have underestimated the prevalence of Covid-19 infection in this transplant population. Furthermore, we were unable to address whether cardiovascular risk factors, immunosuppression, or HT status itself increased the risk of mortality among this population.”

Latif and colleagues said the 25% case fatality rate was “much higher than currently reported in other patient populations.”

The median age of patients was 64 and 22 of them were men. Time from heart transplant ranged from a little over 4 years to more than 14 years, but the average time since transplant was 8.6 years.

As might be expected, the patients had a number of comorbidities, including:

  • Hypertension in 20 patients (71%).
  • Diabetes in 17 patients (61%).
  • Cardiac allograft vasculopathy in 16 patients (57%).

Additionally, “7 of 28 (25%) were obese (body mass index [calculated as weight in kilograms divided by height in meters squared] >30), 10 of 28 (36%) had stage IV or greater chronic kidney disease (with 5 [18%] on hemodialysis)… and 4 of 28 (14%) had preexisting allograft dysfunction,” the study authors wrote.

Most of the patients presented with fever (83%) and dyspnea or cough (91%). Gastrointestinal symptoms were present in almost half of the patients (48%).

Of the HT patients diagnosed with Covid-19, 22 (79%) patients were hospitalized, while six (21%) were managed as outpatients. All of the deaths occurred among hospitalized patients. Eleven (50%) of the hospitalized patients were discharged and four (18%) remained hospitalized at the end of the study (April 24).

“Evidence of myocardial injury was present in 13 patients (77%), and the median peak high-sensitivity troponin T level was 0.055 (0.0205-0.1345) nanograms per milliliter… Inflammatory parameters were markedly elevated, in that high sensitivity C-reactive protein was greater than normal in all patients, with a median (IQR) peak of 11.83 (7.44-19.26)milligrams per deciliter… interleukin 6 was elevated in 15 patients (88%), with a median (IQR) peak of 105 (38-296) picograms per milliliter; and D-dimer was greater than 1 microgram per milliliter in 14 patients (82%),” they wrote.

Twenty patients required supplemental oxygen — including seven who were intubated — and “de novo dialysis was required in 3 patients.”

Covid-19 directed treatments included high-dose corticosteroids in eight patients, hydroxychloroquine in 18 patients, and interleukin 6 receptor agonist in six patients.

“Most patients in this case series had their immunosuppression medications reduced following diagnosis, although the population size is too small to evaluate the effectiveness of this strategy. Whether immunosuppression can temper the immune dysregulation seen in cases of severe disease remains unknown. The high case fatality rate in this cohort does not suggest a protective benefit from immunosuppression; however, randomized studies to assess each individual immunosuppressive agent would be needed to provide a definitive answer,” the authors wrote.

They pointed out that managing heart transplant patients “with Covid-19 has increased complexity because they have more intense immunosuppression than many other solid organ transplant recipients, combined with the potential for the virus to cause both primary and secondary myocardial injury. Although our cohort is small, we recommend that patients who have received HT are treated at a transplant center while infected with Covid-19. Furthermore, these patients will require ongoing monitoring in the recovery phase as an immunosuppression regimen is reintroduced and the consequences to the allograft itself become apparent. The high case fatality rate in this cohort calls for close monitoring of recipients of HT and a low threshold for hospitalization during acute infection with Covid-19.”

  1. One in four heart transplant recipients infected with SARS-CoV-2 died, although immunosuppressive therapy was reduced in most of the 28 patients studied.

  2. Be aware that this small, observational study suggests that heart transplant recipients are at high risk for severe complications from Covid-19 and, since management of these patients is complex, treatment should take place in a transplant center.

Peggy Peck, Editor-in-Chief, BreakingMED™

Latif had no disclosures.

Co-author Yoshifumi Naka, MD, PhD reported personal fees from Abbott, CryoLife, and Zimmer-Biomet outside the submitted work.

Cat ID: 631

Topic ID: 630,631,631,634,190,520,926,192,927,151,928,925,934,312,635