Abstract:As the coronavirus disease 2019 (COVID-19) pandemic ensues, it has posed a greater challenge in heart transplant recipients, a particularly vulnerable patient cohort. Transplant recipients are likely susceptible given the immunosuppressed state, presence of co-morbidities including hypertension, diabetes mellitus, and chronic kidney disease, and frequent contact with the healthcare system, leading to an overall increase in mortality. The attributable risk, however, is largely unknown. Preliminary reports sugge… Show more
Summary
Available data on clinical presentation and mortality of coronavirus disease‐2019 (COVID‐19) in heart transplant (HT) recipients remain limited. We report a case series of laboratory‐confirmed COVID‐19 in 39 HT recipients from 3 French heart transplant centres (mean age 54.4 ± 14.8 years; 66.7% males). Hospital admission was required for 35 (89.7%) cases including 14/39 (35.9%) cases being admitted in intensive care unit. Immunosuppressive medications were reduced or discontinued in 74.4% of the patients. After a median follow‐up of 54 (19–80) days, death and death or need for mechanical ventilation occurred in 25.6% and 33.3% of patients, respectively. Elevated C‐reactive protein and lung involvement ≥50% on chest computed tomography (CT) at admission were associated with an increased risk of death or need for mechanical ventilation. Mortality rate from March to June in the entire 3‐centre HT recipient cohort was 56% higher in 2020 compared to the time‐matched 2019 cohort (2% vs. 1.28%,
P
= 0.15). In a meta‐analysis including 4 studies, pre‐existing diabetes mellitus (OR 3.60, 95% CI 1.43–9.06,
I
2
= 0%,
P
= 0.006) and chronic kidney disease stage III or higher (OR 3.79, 95% CI 1.39–10.31,
I
2
= 0%,
P
= 0.009) were associated with increased mortality. These findings highlight the aggressive clinical course of COVID‐19 in HT recipients.
Summary
Available data on clinical presentation and mortality of coronavirus disease‐2019 (COVID‐19) in heart transplant (HT) recipients remain limited. We report a case series of laboratory‐confirmed COVID‐19 in 39 HT recipients from 3 French heart transplant centres (mean age 54.4 ± 14.8 years; 66.7% males). Hospital admission was required for 35 (89.7%) cases including 14/39 (35.9%) cases being admitted in intensive care unit. Immunosuppressive medications were reduced or discontinued in 74.4% of the patients. After a median follow‐up of 54 (19–80) days, death and death or need for mechanical ventilation occurred in 25.6% and 33.3% of patients, respectively. Elevated C‐reactive protein and lung involvement ≥50% on chest computed tomography (CT) at admission were associated with an increased risk of death or need for mechanical ventilation. Mortality rate from March to June in the entire 3‐centre HT recipient cohort was 56% higher in 2020 compared to the time‐matched 2019 cohort (2% vs. 1.28%,
P
= 0.15). In a meta‐analysis including 4 studies, pre‐existing diabetes mellitus (OR 3.60, 95% CI 1.43–9.06,
I
2
= 0%,
P
= 0.006) and chronic kidney disease stage III or higher (OR 3.79, 95% CI 1.39–10.31,
I
2
= 0%,
P
= 0.009) were associated with increased mortality. These findings highlight the aggressive clinical course of COVID‐19 in HT recipients.
“…Based on the above discussion, available trial data, experience with immunosuppressive regimen, and a previously developed algorithm for management of COVID19 in OHT patients, [20] we suggest a treatment strategy that is summarized in figure 1 . Figure 1 Flow diagram delineating suggested treatment strategy in heart transplant patients with COVID19 infection *Mild infection: O2 sat >94% on room air, without tachypnea, without pneumonia on imaging, and without end organ dysfunction (eg.…”
COVID19 has resulted in many challenges in patient care especially high-risk populations such as heart transplant patients. Patients with heart transplant experience a significantly higher mortality rate with COVID19 infection, and management is based on extrapolation from clinical trials done on non-transplant patients, and from clinical experience. Here we report four cases of heart transplant patients who presented in late 2020 with COVID19 infection. Patients presented with symptoms similar to those seen in the general population. All four patients were admitted to the hospital, and they were all treated with dexamethasone. In addition, two patients received remdesivir. Immunosuppressive medications were adjusted to maintain adequate levels of immunosuppression, but at the same time allowing for an adequate immune response against the infection. All patients were discharged alive from the hospital. We then performed a literature review on studies that included heart transplant patients who developed the infection, and suggest a standardized management approach accordingly.
Background: The clinical impact of severe coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in immunocompromised patients has not been systematically evaluated. Methods: We reviewed current literature reporting on COVID-19 in cancer (CA), hematopoietic cell (HCT), and solid organ transplant (SOT) patients and compared their clinical data and outcomes to the general population. For adult CA, HCT and SOT patients, an extensive search strategy retrieved all articles published until July 20, 2020 by combining the terms coronavirus, coronavirus infection, COVID-19 , and SARS-CoV-2 in PubMed, Cochrane, and Web of Science, and following the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. For the pediatric CA cohort, a global COVID-19 registry was used. For the general population cohort, a large meta-analysis was used to compare pooled prevalence estimates, and two large meta-analyses were utilized to serve as pooled comparators for hospitalized COVID-19 patients. Findings: Compared to the general population, adult CA and SOT patients with COVID-19 had higher comorbidities, greater levels of inflammatory markers at diagnosis, and higher rates of intensive care and hospital mortality. Pediatric CA patients and HCT patients with COVID-19 tended to have clinical presentations and outcomes similar to the general population. Interpretation: To our knowledge, this is the first systematic review evaluating COVID-19 phenotype and outcomes in immunocompromised patients and comparing them to the general population, which shows that hospital outcomes appear to be worse in adult CA and SOT patients, potentially due to their higher co-morbidity burden.
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