Hearts from donors with COVID-19 at time of death may confer worse survival for recipients
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Key takeaways:
- Recipients of hearts from donors with active COVID-19 had elevated risk for death at 6 months and 1 year.
- The same was not true for recipients of hearts from donors recently recovered from COVID-19.
Transplant recipients with donor hearts from people who had active COVID-19 at time of death had worse 6-month and 1-year survival outcomes than those who had hearts from donors recovered from or without COVID-19, researchers reported.
However, there was no difference in survival between recipients with a heart from a donor who recovered from COVID-19 just before death and those with a heart from a donor who did not have COVID-19.
Data were derived from Madan S, et al. J Am Coll Cardiol. 2023;doi:10.1016/j.jacc.2023.04.022.
“These early trends should be concerning enough such that heart transplantation centers need to thoroughly evaluate and continue to weigh the risks/benefits of using hearts from active COVID-19 donors,” Shivank Madan, MD, MHA, FACC, a cardiologist at the Center for Advanced Cardiac Therapy at Montefiore Medical Center/Albert Einstein College of Medicine in New York, said in a press release.
Heart donors and COVID-19 status
The researchers began their study with an analysis of 27,862 donors listed in the United Network for Organ Sharing database between May 2020 and June 2022 with available information on COVID-19 testing and organ disposition. Of those, 1,445 had a positive test for COVID-19 during final hospitalization, and of those, 1,017 were deemed to have active COVID-19 and 428 were deemed to have recovered from COVID-19 before death.
The analysis of adult heart transplant recipients included 5,641 patients (mean age, 57 years; 27% women) who received a heart from a donor who did not have COVID-19, and 239 (mean age, 55 years; 24% women) who received a heart from a donor with COVID-19, of whom 150 had active COVID-19 at time of death and 89 had recently resolved COVID-19 at time of death.
There were no differences between the groups in recipient characteristics, but donors in the COVID-19 group were younger (30 years vs. 32 years; P = .002), less likely to be female (19.67% vs. 27.89%; P = .005) and less likely to have brain anoxia (43.93% vs. 46.13%; P = .023) than donors in the non-COVID-19 group, the researchers found.
Survival outcomes
Compared with recipients of hearts from donors without COVID-19, recipients of hearts from donors with active COVID-19 were more likely to die at 6 months (HR = 1.74; 95% CI, 1.02-2.96; P = .043) and 1 year (HR = 1.98; 95% CI, 1.22-3.22; P = .006), according to the researchers.
However, compared with the non-COVID-19 group, recipients of hearts from donors who had recently resolved COVID-19 before death did not have increased risk for mortality at 6 months (HR = 1.26; 95% CI, 0.56-2.82; P = .579) and 1 year (HR = 1.43; 95% CI, 0.64-2.84; P = .439), Madan and colleagues found.
An analysis based on propensity-score matching did not change the results.
“While the current analysis has a longer follow-up than previous reports, it must be emphasized that this is still early data and continued evaluation of COVID-19 donors with more granular data, larger sample size, longer follow-up and with newer variants of COVID-19 virus is needed,” Madan and colleagues wrote. “The current study highlights importance of continued evaluation and probably the need for a more nuanced approach towards utilizing this new donor pool.”
Reference:
- Using COVID-19 positive donor hearts may impact post-transplant survival. https://www.acc.org/About-ACC/Press-Releases/2023/05/17/18/13/Using-COVID-19-Positive-Donor-Hearts-May-Impact-Post-transplant-Survival. Published May 17, 2023. Accessed May 17, 2023.
Perspective
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The results are surprising given the small single-center study and the UNOS registry study showing no effect on recipient mortality at 35 days.
Based on this information, I would strongly consider not transplanting a heart from a donor with active COVID-19. However, all donor decisions are based on recipient need. If the potential recipient is having complications with bridge-to-transplant support, or if they are on venoarterial extracorporeal membrane oxygenation, use of the expanded donor pool of COVID-19 positive donors could still be considered with full disclosure of the risk/benefit ratio to recipients and their family members.
These data need to be followed for outcomes longer than 1 year. It would also be beneficial to see the outcomes of other organs that were transplanted from the active COVID-19 donors. I agree with the conclusion that COVID-19 status should factor into all decisions regarding the use of this expanded donor pool.
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