key: cord-310862-53g4hjtp
authors: DeFilippis, Ersilia M.; Farr, Maryjane A.; Givertz, Michael M.
title: Challenges in Heart Transplantation in the Era of COVID-19
date: 2020-04-21
journal: Circulation
DOI: 10.1161/circulationaha.120.047096
sha: 
doc_id: 310862
cord_uid: 53g4hjtp

nan

States, particularly in New York, have inactivated most of their HT waiting list, reserving active transplant status for only those patients with a presumed wait list mortality of 1 to 2 weeks, thus limiting transplant to patients in tiers 1 or 2 of the new heart allocation policy. Restrictions are also in effect for highly sensitized patients requiring intensive perioperative care and prolonged immunosuppression and with the need for frequent biopsy surveillance. It is uncertain whether women may be disproportionally affected in access to transplant, given their high sensitivity rates. For listed patients who are hospitalized without a strict contraindication to durable left ventricular assist device implantation, left ventricular assist device as a bridge to transplant may be a viable strategy to get at-risk patients home and out of the hospital, minimizing their exposure to COVID-19. Left ventricular assist device implants should not be performed in elective cases because of resource constraints and potential for nosocomial infection.

These issues of feasibility and safety extend not only to recipients but also to organ donors, organ procurement organizations, and recovery teams. As COVID-19 continues to spread, we must be vigilant in choosing uninfected donors, recognizing that many may be asymptomatic carriers and that current testing has limitations. Chest computed tomography may also be necessary to exclude radiographic pneumonia. In discussing donor offers with listed patients, expanded consent should include the potential risks of a COVID-19-positive donor, despite procedures in place to mitigate risk. It is equally important to protect procurement teams, who are asked to perform time-sensitive, invasive procedures in unfamiliar facilities that may lack appropriate personal protective equipment or experienced operating room staff. Important organ procurement organization measures in the United States include expansion of the Uniform Donor Risk Assessment Interview, which now includes targeted questions on exposure to COVID-19. Mandatory COVID-19 testing for all donors is the goal, which is now occurring with increasing frequency in most regions of the United States. If donors test positive for COVID-19, their organs should not be used for transplant, although they could be considered for scientific purposes to better understand the effects of the virus on the myocardium. COVID-19-specific codes have been used to inform the United Network of Organ Sharing, the federally contracted organization that keeps track of all solid organ transplantation, of the circumstances under which an organ was not accepted. 3 For patients who require HT during this pandemic, rapid polymerase chain reaction testing to exclude community-or hospital-acquired COVID-19 infection is required, and extra precautions should be taken to mitigate the risk of postoperative exposure. This extends to visitors (many of whom are restricted at various hospitals across the country), nurses, respiratory therapists, and other intensive care unit staff. Negative pressure rooms in a COVID-19-free zone should be standard of care. Recipients should be retested before hospital discharge and receive focused education around disease prevention at home.

The changing landscape also affects the post-HT ambulatory population. To reduce hospital volumes, most outpatient practices have shifted toward telemedicine. Virtual medicine minimizes in-person contact with the healthcare system, reducing patient risk of exposure. However, patients still must go to laboratories for serum drug levels of immunosuppressive agents. One question that arises is how we can or should monitor for rejection in stable outpatients if right heart catheterization and endomyocardial biopsy are deemed nonurgent. Perhaps institutions will shift to increased use of noninvasive monitoring with echocardiography, gene profiling (for acute cellular rejection), or donor-derived cell free DNA (for antibodymediated rejection). What is considered "medically necessary" for these patients? What will be the implications of postponing some of this routine care on the rates of rejection or cardiac allograft vasculopathy in the longer term?

Multidisciplinary HT teams must counsel patients and families on appropriate preventative measures. In 1 epidemiological study in China of 87 HT recipients, 97% adopted prevention and quarantine measures with a low rate of infection. 5 We should recognize that given their immunosuppressed states, these patients may have both typical (respiratory) and atypical (gastrointestinal) COVID-19 illness. For HT patients admitted with COVID-19 infection, some have advocated for reduced immunosuppression and moderate-dose IV steroids.

The role of novel therapy (eg, remdesivir, tocilizumab) should be tested in clinical trials before treatment algorithms are promulgated widely, with particular attention to drug-drug interactions and QT prolongation.

Many questions remain, and the available knowledge on the virus and its impact on special populations is rapidly evolving (Table) . As a community, we have a responsibility to share information in real time, gather more research, and provide guidance to other transplant providers, our multidisciplinary teams, and patients. Transparency with patients and other centers is key for the transplant community to come through this pandemic stronger. 

None.

COVID-19 and cardiovascular disease

First cases of COVID-19 in heart transplantation from China

United Network for Organ Sharing. COVID-19 and solid organ transplant

COVID-19: a global transplant perspective