Transplanting COVID-19–Positive Donor Hearts

In March 2020, as hospitals across the country were reeling from the catastrophic impacts of SARS-CoV-2, the United Network of Organ Sharing appropriately introduced organ refusal code 841 to be used when an offer is refused because of a donor-related COVID-19 reason. At the time, little was known about SARS-CoV-2, and the potential risks of proceeding to transplantation in the setting of donor SARS-CoV-2 positivity were deemed prohibitive for potential recipients, donor procurement teams, and implanting surgical teams. Since then, many deceased donor organs—including donor hearts—have been refused primarily for this reason. Indeed, between August 2020 and September 2021, the heart nonrecovery rate from COVID-19–infected donors was 87%, compared with 35% from noninfected donors.¹

Three years later while the SARS-CoV-2 pandemic persists, much of what we know about the virus has changed, and so too has our health care response. Within the transplantation community and elsewhere, effective vaccines and treatments have reduced the likelihood of COVID-related hospitalization and death, hospitals are better equipped to care for patients and providers using personal protective equipment and rapid-turnaround testing, and COVID testing and isolation protocols have been refined. In addition, our understanding of the significance of donor SARS-CoV-2 positivity has evolved. Although viral RNA has been detected after death in cardiomyocytes, renal tubular cells, and hepatocytes of individuals who died predominantly of severe COVID-19, prompting initial concerns that donor-derived infections could occur in nonlung organ recipients, there are no data to date demonstrating that viable, transmissible virus exists in organs outside the respiratory tract. Moreover, in nonlung recipients of organs from donors whose test results are positive for SARS-CoV-2, there have been no cases of disease transmission and similar short-term outcomes in comparison with recipients of organs from COVID-19–negative donors. In a propensity-matched analysis of the OPTN (Organ Procurement and Transplantation Network) database that included patients undergoing heart transplantation between February 2021 and March 2022, the first 84 consecutive recipients from COVID-19–positive donors experienced similar 30-day survival, hospital length of stay, and rates of graft failure, postoperative stroke, and dialysis as did 3,205 recipients from uninfected donors.²

Despite these encouraging data, code 841 (now renumbered 744) continues to be a commonly cited reason for donor heart refusal, and heart utilization rates from COVID-19–positive donors remain low. Between May 2021 and January 2022, the utilization rate of hearts from COVID-19–positive donors was only 17.2%, compared with 28% for all other donors,³ and as of February 2022 fewer than half of 78 adult and pediatric transplantation medical director survey respondents indicated a willingness to consider donors with positive SARS-CoV-2 polymerase chain reaction test results.⁴ All the while the gap between donor heart supply and demand continues to grow, as do cardiac waitlist times. Among waitlisted pediatric patients, wait times during the initial period of the COVID-19 pandemic (March 2020 to June 2021) were 31.4% longer than during the prepandemic period (November 2018 to February 2020).⁵

In light of the available evidence, and with SARS-CoV-2 here to stay, the question becomes not whether and why to transplant hearts from COVID-19 positive donors but rather how and why not?

As is often the case, taking a lesson from the pages of history may prove helpful. We have long understood that donor-related viruses play an important role in affecting post-transplantation outcomes. Most notable is cytomegalovirus (CMV) disease, the risk of which is much greater in CMV-seronegative recipients when the donor is CMV seropositive (D+/R−). More than 75% of solid organ transplantation patients are newly infected or experience reactivation of latent CMV after transplantation, and CMV has been associated with numerous poor outcomes, including acute rejection, chronic allograft failure, and mortality. And yet, we routinely accept CMV mismatched donor organs for waitlisted candidates and then focus after transplantation on CMV prevention. More prominent in recent years is the impact on heart transplantation from donors who are hepatitis C virus (HCV) positive—historically associated with poor outcomes but, since the advent of direct-acting antiviral agents, now a viable strategy associated with excellent short-term outcomes, although longer-term outcomes remain unknown. In the case of donor CMV and donor HCV infection, we knowingly accept some potential long-term risk in order to reap the tremendous up-front benefit: a vastly expanded donor pool. Absent evidence suggesting harm, and with comparable short-term outcomes, why not adopt the same behavior toward donors whose test results are positive for SARS-CoV-2?

Successfully challenging the status quo demands a 2-pronged approach. First, clear, deliberate, and widespread dissemination of the available evidence in the form of expert consensus recommendations from leaders in the field, directed at transplant program and organ procurement organization leadership, will be key in shifting attitudes and changing policy. Second, a strong commitment at the national, regional, and center levels to tracking and reporting outcomes after transplantation from COVID-19–positive donors, especially with regard to the long-term organ-specific sequelae, will be critical. Among the questions to be answered are whether donors with active SARS-CoV-2 infection or who die as a result of COVID-19 sequelae confer noninfectious risks to recipients, including the theoretical risk of increased thrombotic complications in the donor organs, as well as whether the presence of SARS-CoV-2 in cardiac tissue is an innocuous finding vs a harbinger of longer-term organ dysfunction.

As we embark on the third year of the COVID-19 pandemic better armed with scientific knowledge and discovery, it is the obligation of leaders in the heart transplantation community to build on our recent experience from other donor viral infections and embrace the emerging evidence that transplantation of SARS-CoV-2–positive donor hearts is no longer an unknown threat but rather an opportunity that—similar to donor CMV and HCV—can safely increase the use of donor hearts to shorten waitlist times and improve survival for the growing list of patients in need of heart transplantation.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.