Infection with coronavirus disease 2019 (COVID-19) was found to be associated with a case fatality rate of 25% in heart transplant recipients at a heart transplant center in New York City, according to data published in JAMA Cardiology.
Heart transplant recipients are subject to several comorbidities and clinically significant immunosuppression that may put them at increased risk for adverse outcomes attributable to infection with COVID-19. In this case series from a single academic heart
transplant program in New York City, data from follow-up assessments of heart transplant recipients between March 1, 2020, and April 24, 2020 were analyzed.
A diagnosis of COVID-19 was confirmed in 28 heart transplant recipients. The median age was 64.0 (interquartile range [IQR], 53.5-70.5) years, 79% were men, and the median time from heart transplantation was 8.6 (IQR, 4.2-14.5) years. Reported comorbid conditions among the study population included hypertension (20 [71%]), diabetes (17 [61%]), and cardiac allograft vasculopathy (16 [57%]). Twenty-two patients were admitted for treatment, with 7 requiring mechanical ventilation; complete laboratory data were available for 17 hospitalized patients
Evidence of myocardial injury was identified in 13 of the 17 patients (median peak high-sensitivity troponin T, 0.055 ng/mL [IQR, 0.0205-0.1345]. Elevated inflammatory biomarkers included a median peak high-sensitivity C-reactive protein of 11.83 mg/dL [IQR, 7.44-19.26] noted in all patients, as well as a median peak interleukin 6 that was found to be elevated in 6 patients (105 pg/mL [IQR, 38-296]). Mycophenolate mofetil immunosuppression was discontinued in 16 patients, and the dose of calcineurin inhibitor was reduced for 6 patients. Treatment for COVID-19 included hydroxychloroquine in 18 patients, high-dose corticosteroids in 8 patients, and interleukin 6 receptor antagonists in 6 patients. Among the 22 patients who were admitted to the institution, 11 were discharged home, 4 remained hospitalized at the end of the study, and 7 died during hospitalization.
The investigators note that prevalence of COVID-19 in this population may have been underestimated as asymptomatic patients were not routinely tested, and there were limitations on testing mildly symptomatic individuals at the earliest phase of the pandemic. The investigators were also unable to address whether cardiovascular risk factors, immunosuppression, or heart transplant status increased the risk of mortality associated with COVID-19, and the effect of immunosuppression on the course of the disease is still unclear. Although most patients underwent reductions in their immunosuppression medications, the sample size is too small to evaluate the effectiveness of this strategy. Therefore, randomized studies “to assess each individual immunosuppressive agent would be needed to provide a definitive answer.”
According to the investigators, the high case fatality rate among this cohort indicates a need for close monitoring of heart transplant recipients and a low threshold for hospitalization during acute infection with COVID-19. They further advise that, “although our cohort is small, we recommend that patients who have received heart transplants [and are infected with COVID-19] are treated at a transplant center.”
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