COVID-19 Donor Hearts Linked to Lower Survival in Transplant Patients

Shivank Madan, MD, MHA
Credit: Montefiore Medical Center

A study from investigators at the Albert Einstein College of Medicine is raising a red flag related to the potential impact of using COVID-19-positive donor hearts on post-transplant survival.

Results of the study, which examined more than 27,000 donors in the United Network for Organ Sharing (UNOS), indicate those receiving active COVID-19-positive donor hearts had nearly double the risk of mortality at 6 months and more than doubled risk for mortality at 1 year compared to their counterparts who received non-COVID donor hearts. However, investigators noted those receiving transplants from recently resolved COVID-19 donors had similar 6-month and 1-year mortality rates as those receiving non-COVID donor hearts.

“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,” said lead investigator Shivank Madan, MD, MHA, a cardiologist at the Center for Advanced Cardiac Therapy at Montefiore Medical Center/Albert Einstein College of Medicine in New York.²

By 2023, the COVID-19 pandemic has impacted life across the globe. According to the US Centers for Disease Control and Prevention (CDC), COVID-19 has been responsible for more than 6 million total hospitalizations and more than 1.1 million deaths in the US since the pandemic began. Although headlines related to COVID-19 have been innumerable in both magnitude and the different subject areas examined, a consistent theme in much of the coverage has been the impact on long-term health, including cardiovascular health.

In the current study, Madan and colleagues from the Montefiore Medical Center of the Albert Einstein College of medicine sought to examine characteristics and outcomes of heart transplants using heart from COVID-19 donors relative to those from donors without COVID-19. To do so, investigators designed their research endeavor as Ana analysis of data obtained from UNOS. A private, nonprofit collecting data from transplants hospitals and organ procurement organizations, the UNOS database provided investigators with information related to 27,862 donors with 60,699 COVID-19 nucleic acid tests (NAT) from the study period, which was defined as May 2020-June 2022.

For the purpose of analysis, donors were considered COVID-19 donors if NAT was positive at any time during terminal hospitalization and subclassified as active-COVID-19 if NAT was positive within 2 days of organ procurement or recently-resolved COVID-19 if NAT positive initially but NAT negative prior to procurement. Investigators pointed out donors with positive NAT more than 2 days prior to procurement were considered as active-COVID-19 unless there was evidence for subsequent negative NAT 48 hours or more after last positive NAT test.

During the study period, investigators identified 1445 COVID-19 donors. Of these, 1017 were considered active-COVID-19 and 428 were considered recently-resolved COVID-19. A total of 309 heart transplants utilizing COVID-19 donors and 239 adults heart transplants from COVID-19 donors met study criteria. Of the 239 transplants from COVID-19 donors, 150 met the criteria for active-COVID-19 and 89 met the criteria for recently-resolved COVID-19.

Relative to non-COVID-19 donors, investigators noted COVID-19 donors were similar in age (55 [42-63] vs 57 [46-64] years), female gender (23.85% vs 27.03%), Black race (23.43% vs 24.22%), size mismatch (12.13% vs 11.59%), ischemic etiology (29.29% vs 28.01%), UNOS urgency status, intra-aortic balloon pump (27.20% vs 26.98%), LVAD (29.71% vs 30.99%) or ECMO support (5.02% vs 5.78%) (all P >.05).

When examining outcomes, results indicated heart transplants from active-COVID-19 donors were associated with an increased risk of 6-month (Hazard ratio [HR], 1.74 [95% Confidence interval [CI], 1.02-2.96]; P=.043) and 1-year (HR, 1.98 [95% CI, 1.22-3.22]; P=.006) relative to their counterparts receiving transplants from non-COVID-19 donors. Further analysis demonstrated similar mortality rates week observed at 6 months and 1 year when comparing rates among those with recently-resolved and non-COVID-19 donors. Investigators also highlighted similar results were observed in propensity-matched cohorts.

Investigators called attention to increasing use of COVID-19 donors during the pandemic but noted transplant centers were selective and the majority of used donor heart were from younger donors and approximately 80% were male. Investigators urged consideration of the study’s limitations before overinterpretation of results. Specific limitations highlighted by investigators included variation in the timing and frequency of COVID-19 testing during terminal hospitalization as well as a lack of information related to COVID-19 disease activity, including date of disease onset and symptom burden or vaccination status of donor or recipient.

References:

1. Hsu JJ, Al-Saffar F, Ardehali R, et al. Heart transplantation in the early phase of the COVID-19 pandemic: A single-center case series. Clin Transplant. 2020;34(9):e14042. doi:10.1111/ctr.14042
2. Using covid-19 positive donor hearts may impact post-transplant survival. American College of Cardiology. May 17, 2023. Accessed May 17, 2023. https://www.acc.org/About-ACC/Press-Releases/2023/05/17/18/13/Using-COVID-19-Positive-Donor-Hearts-May-Impact-Post-transplant-Survival.
3. Centers for Disease Control and Prevention. COVID Data Tracker. Atlanta, GA: US Department of Health and Human Services, CDC; 2023, May 17. https://covid.cdc.gov/covid-data-tracker