High Fatality Rate in Heart Transplant Recipients With COVID-19

Novel coronavirus disease 2019 (COVID-19) was found to be associated with a higher fatality rate in recipients of heart transplant, according to a case series published in JAMA Cardiology.

Heart transplant recipients may be at increased risk for complications of COVID-19 due to a high burden of comorbidities and treatment with immunosuppressive agents. However, immunosuppression has also been proposed as a possible option for treatment of COVID-19, as it may curbthe“cytokine storm” that has been observed in severe cases.

Withthis retrospective review of adult heart transplant recipients at a large academic center in New York, New York, investigators aimed to determine the outcomes of heart transplant recipients with COVID-19 while receiving chronic immunosuppression.

In this cohort of 803 heart transplant recipients, 28 patients (79% men; mean age, 64.0 years) received a laboratory-confirmed diagnosis of COVID-19 at a median 8.6 years (interquartile range, 4.2-14.5 years) aftertransplant. Hypertension was the most frequently observed comorbidity (71%), follow by diabetes mellitus (61%) and cardiac allograft dysfunction (57%). Patients commonly presented with dyspnea or cough (91%), fever (83%), and gastrointestinal symptoms (48%).

Of the 22 patients (79%) who were admitted for treatment, 7 required admission to the intensive care unit. Supplemental oxygen was required for 20 patients, 7 of whom required intubation. Laboratory data were available for 17 patients. The majority of patients (77%) had evidence of myocardial injury (median peak high-sensitivity troponin T level, 0.055 ng/mL). Inflammatory markers were also elevated (median peak high-sensitivity C-reactive protein level, 11.83 mg/dL; median peak interleukin-6 level, 105 pg/mL). Echocardiogram was performed during hospitalization for 7 patients. Compared with the most recent echocardiogram, left ventricular ejection fraction was unchanged for most patients (n=5).

Baseline immunosuppressive medications included calcineurin inhibitors (96%), mycophenolate mofetil (68%), corticosteroids (68%), and proliferation signal inhibitors (18%). Mycophenolate mofetil was discontinued in 70% of patients. Calcineurin inhibitor dosage was reduced in 26% of patients. Treatment of COVID-19 symptoms included hydroxychloroquine (n=18), high-dose corticosteroids (n=8), and interleukin 6 receptor antagonist (n=6).Over the course of the study period, 7 patients (25%) died and an additional 4 were still hospitalized at the end of the study.

The investigators noted that the relatively small cohort size represented a limitation of the study.

“The high case fatality rate in this cohort calls for close monitoring of recipients of [heart transplant] and a low threshold for hospitalization during acute infection with COVID-19,” the study authors concluded. “The high case fatality rate in this cohortdoes not suggest a protective benefit from immunosuppression; however, randomized studies to assess each individual immunosuppressive agent would be needed to provide a definitive answer.”

Disclosure: Dr. Naka reported affiliations with the pharmaceutical industry. Please see the original reference for a full list of disclosures.

Reference

Latif F, Farr MA, Clerkin KJ, et al. Characteristics and outcomes of recipients of heart transplant with coronavirus disease 2019 [published online May 13, 2020]. JAMA Cardiol. doi:10.1001/jamacardio.2020.2159