Heart transplantation, deceased donor recovery rates drop amid pandemic
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Researchers reported significant fluctuations in heart transplant waitlist inactivations, waitlist additions, donor recoveries and transplant volume since the onset of the COVID-19 pandemic in mid-March.
“Understandably, there has been increasing emphasis and accumulation of data regarding treatment and complications of COVID-19,” Ersilia M. DeFilippis, MD, fellow in cardiovascular medicine at NewYork-Presbyterian Hospital, told Healio. “However, there are equally important effects on care delivery for uninfected patients with acute and chronic medical conditions. Despite regional variation in COVID-19 prevalence, the rate of heart transplantation decreased nationally without significant variation between areas of the country. This highlights that although the pandemic had clear impact on regional changes in practice, there were still unforeseen consequences for patients waiting for heart transplant in other areas of the country.”
For this cross-sectional study, published in JAMA Cardiology, investigators used publicly available data from the United Network for Organ Sharing (UNOS) and the CDC to assess changes in waitlist inactivations and additions, deceased donor recovery and transplant volumes from the pre-COVID-19 period of Jan. 19 to March 15 compared with the COVID-19 period of March 15 to May 9.
Waitlist inactivations increase as new additions drop
Researchers observed that from the pre-COVID-19 to the COVID-19 period, waitlist inactivations increased by 75%, of which 67% were due to COVID-19 precaution.
During the COVID-19 era, new additions to the heart transplant waitlist decreased by 38% compared with the prior 8-week period.
Investigators observed that all regions in the U.S., with the exception of the South, Midwest and Northwest, experienced drops in new waitlist additions, with the largest decreases reported in the Northeast (69% decrease), Great Lakes (52% decrease) and the Southwest (42% decrease). Meanwhile in the South Midwest, heart transplant waitlist additions increased by 8.5%.
“The decrease in waitlist inactivations was not particularly surprising given our experience in the Northeast where many patients were removed from the waitlist with the exception of the sickest patients with presumed waitlist mortality of 1 to 2 weeks,” DeFilippis said in an interview. “With regard to waitlist additions, we suspect that many evaluations for heart transplantation (which require multiple consultations with specialists and outpatient testing) had been delayed due to restrictions on elective procedures and minimizing outpatient encounters.”
Drops in deceased donor recovery
Overall, adult deceased donor recovery decreased by 26% between the two periods. This change was observed on a national level, even in regions with lower prevalence of COVID-19 infection.
Moreover, the largest drop was found in the North Midwest with a decrease in deceased donor recovery of 41%.
“COVID-19 was present in some communities earlier than March 2020. Therefore, some waitlist inactivations before March 15, 2020, may have been secondary to COVID-19 but were unable to be coded as such in UNet (the electronic system managed by UNOS that allows transplant professionals to submit, store and manage transplant-associated data),” the researchers wrote. “Nevertheless, we also examined overall trends in inactivations. Donor COVID-19 status was not available for analysis.”
According to the study, heart transplant volume decreased by 26% across the U.S. from the pre-COVID-19 era to the COVID-19 era. In addition, there was no regional variation in transplant volume fluctuation amid the COVID-19 era (17% change in the Southeast vs. 19% in the Southwest; P = .07).
“As COVID-19 cases continue to surge in different areas of the country, the patterns visualized in the Northeast and Great Lakes may replicate themselves in other areas,” Defilippis told Healio. “In the coming months to years, it will be important to assess if there were any changes in waitlist survival for patients or changes in patterns of left ventricular assist device implantation. Similarly, those who did receive heart transplantation represented the sickest patients and this may impact post-transplant survival.”
Perspective
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Frank Smart, MD
This is a very interesting paper that demonstrates the far-reaching effect of COVID-19 on medical resource utilization and downstream effects of stay-at-home mandates and social distancing. The manuscript further characterizes effects on cardiac transplantation by region, and the data supports the authors’ hypothesis that in those areas with a higher COVID-19 density there was a greater effect on heart transplantation.
I believe the decrease in transplantation probably had more to do with ICU bed availability during the peak of COVID-19 hospitalizations. Fewer ICU beds were available to manage brain dead donors. Additionally, no elective or even urgent cases were being performed in hospitals most dramatically affected by SARS-CoV-2 because they had exceeded ICU capacity. This was certainly the case in the Northeast. Waiting list additions would have also been impacted by allocating hospital resources to patients with or suspected to have COVID-19. Since no elective or semi-elective clinic visits or hospital admissions occurred during this time, fewer people would have completed the transplant work-up and have been ready for selection committee presentation and subsequent listing.
The fact that states like Texas and Arizona had a later peak SARS-CoV-2 ICU bed shortage may serve to validate these data even further, if similar findings exist in those regions from a later time point than when these data were acquired.
There may also be downstream effects yet to be observed, since individuals who did undergo cardiac transplantation during this time were likely severely ill with no bridging options. If that is the case, we may see reduced post-transplant survival in those areas next year.
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