Challenges in Heart Transplantation in the Era of COVID-19

Abstract

he cardiovascular community faces unprecedented challenges during the coronavirus disease 2019 (COVID-19) pandemic.For heart transplant (HT) clinicians, the global pandemic has unique implications for patients, including those on the waiting list and transplant recipients.These populations are at increased risk for both acquisition of COVID-19 infection and progression to severe disease given multiple healthcare contacts, underlying health conditions, and immunosuppression; targeted prevention and treatment strategies are needed.Past experience with previous coronavirus epidemics such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) demonstrated that transplant patients had similar presentations to the general population. 1 Data are rapidly accumulating on the impact of COVID-19 within the transplant community.COVID-19 cases have already been reported in 2 HT recipients in China.Both patients survived, one with a mild form of illness allowing for treatment and recovery at home, the other with progressive respiratory failure requiring inpatient admission, intravenous immunoglobulin, and methylprednisolone. 2 Mild-moderate presentations with uncomplicated courses have also been reported after kidney and liver transplant.Since these initial reports, a growing number of solid organ transplant recipients have been hospitalized for COVID-19, particularly in New York City.In-hospital disease transmission is increasing, with hospitals increasingly cohorting patients with COVID-19 in separate intensive care units and wards, irrespective of transplant status.Specific to HT recipients, manifestations of myocarditis-with high troponin levels, ECG changes, and new left ventricular dysfunction-may be mistaken for rejection.Yet endomyocardial biopsies are being restricted because of risks of exposure.The scope and scale of the current epidemic are unmatched, and online reports raise concerns about rapidly progressive disease leading to morbidity and mortality. 3mportant decisions have already arisen about actively listed patients.At any given time, a significant portion of patients are waiting in-hospital for HT.These patients are at higher risk for contracting the virus compared with others waiting at home.If they are subsequently infected with COVID-19, they are at risk for more severe infection (or coinfection) because of their underlying health conditions, and risk delisting.If possible, these patients should not be cared for by nurses who also have COVID-19-positive patients.However, as cases continue to rise, this may not be feasible.For all listed patients, no matter whether they are hospitalized or at home, transplant centers should highlight the wait list mortality risk-benefit ratio and provide institutional updates by direct telephone communication or a letter followed by a telephone communication.As the pandemic continues to evolve, a center's transplant volume may require staged reduction to meet intensive care unit bed, staffing, and medical equipment needs of the majority nontransplant population. 4Many centers in the United

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