Heart transplantation is the gold standard treatment for Stage D heart failure and is primarily limited by the donor pool. Transplantation rates and additions to the wait list have decreased during the pandemic, in part because of concerns surrounding use of allografts from SARS-CoV-2–positive donors.1 The United Network for Organ Sharing (UNOS) has issued summary recommendations on transplantation from potential donors with a history of or active, but mild or asymptomatic, cases of SARS-CoV-2 infection stratified by time since disease onset.2 The extent of cardiac injury after mild SARS-CoV-2 infection is an active area of investigation. Although clinical evidence of cardiac injury is rare in otherwise healthy, young infected persons,3 endothelial dysfunction4 and subcellular derangements5 could theoretically have longer-term consequences for a mild or subclinical infection in the transplanted organ.
To understand the clinical outcomes of patients who received cardiac allografts from SARS-CoV-2–infected donors, we queried the UNOS thoracic organ registry for patients undergoing cardiac transplantation from March 1, 2020, to December 1, 2021. We identified recipients of organs from SARS-CoV-2–positive donors by nucleic acid amplification testing and compared them with recipients of SARS-CoV-2–negative donors. Recipients of organs from donors with indeterminant results were not included. Recipients with missing posttransplantation survival information were not included (399 from SARS-CoV-2–negative donors, 11 from SARS-CoV-2–positive donors). The primary outcome of interest was patient post-transplantation mortality. Student’s t, Mann-Whitney U, and chi-square tests, as appropriate, and Kaplan-Meier comparisons were performed. This study was approved as exempt by the Yale School of Medicine Institutional Review Board.
During the study period, hearts from 37 SARS-CoV-2 test positive donors were accepted for transplantation (Table 1 ). Compared with declined donors, the accepted organs came from donors who were younger (median age: 28 vs 47 years; P < 0.001), less likely female (8.1% vs 39.1%; P = 0.002), and of lower body mass index (27.0 vs 31.6 kg/m2; P = 0.001). Accepted hearts had higher ejection fraction (median: 64% vs 60%; P = 0.04), and were less likely to be donated after circulatory death (8.1% vs 56.4%; P < 0.001). Of these 37 donations, we identified 32 recipients of organs from SARS-CoV-2–positive donors and compared them with 5,445 recipients of allografts from SARS-CoV-2–negative donors over the same period. There were no differences in age, gender, body mass index, urgency status at transplantation, blood type distribution, pretransplantation support, or comorbidities. Thirty-day and 1-year survival was 100% for the recipients of organs from SARS-CoV-2–positive donors, and there were no apparent differences in short-term survival compared with recipients of organs from SARS-CoV-2–negative donors (P = 0.342 at 30 days; P = 0.218 at 1 year).
Table 1.
Accepted and Declined SARS-CoV-2 Positive Donor Characteristics and Recipient Characteristics of Hearts From SARS-CoV-2 Positive and Negative Donors
| SARS-CoV-2 NAAT Positive Donors |
Recipient Characteristics |
|||||
|---|---|---|---|---|---|---|
| Heart Declined (n = 243) | Heart Accepted (n = 37) | P Value | SARS-CoV-2 NAAT Negative Donor (n = 5,445) | SARS-CoV-2 NAAT Positive Donor (n = 32) | P Value | |
| Age, y | 47 (35-55) | 28 (22-36) | <0.001 | 56 (46-63) | 58 (46-64) | 0.578 |
| Female | 39.1 | 8.1 | 0.002 | 26.28 | 18.75 | 0.334 |
| Body mass index, kg/m2 | 31.6 (26.3-36.6) | 27.0 (24.6-30.8) | 0.001 | 27.6 (24.2-31.5) | 28.3 (24.3-30.8) | 0.881 |
| Blood type | 0.205 | 0.787 | ||||
| A | 41.2 | 35.1 | 38.8 | 50.0 | ||
| AB | 4.1 | 0.0 | 5.0 | 0.0 | ||
| B | 11.1 | 5.4 | 15.4 | 12.5 | ||
| O | 43.6 | 59.5 | 40.8 | 37.5 | ||
| Ethnicity | 0.143 | 0.172 | ||||
| White | 70.4 | 51.4 | 62.2 | 43.8 | ||
| Black | 9.5 | 18.9 | 16.5 | 21.9 | ||
| Hispanic | 16.5 | 27.0 | 17.9 | 31.3 | ||
| AAPI | 1.2 | 0.0 | 1.7 | 0.0 | ||
| UNOS region | 0.434 | 0.040 | ||||
| 1 | 0.4 | 0.0 | 3.4 | 0.0 | ||
| 2 | 8.7 | 2.3 | 9.2 | 3.1 | ||
| 3 | 8.7 | 9.1 | 15.8 | 9.4 | ||
| 4 | 13.2 | 15.9 | 10.4 | 18.8 | ||
| 5 | 14.9 | 15.9 | 16.0 | 12.5 | ||
| 6 | 4.5 | 2.3 | 4.0 | 0.0 | ||
| 7 | 4.2 | 2.3 | 7.8 | 0.0 | ||
| 8 | 21.2 | 18.2 | 7.7 | 15.6 | ||
| 9 | 2.8 | 9.1 | 3.7 | 12.5 | ||
| 10 | 12.9 | 9.1 | 10.0 | 12.5 | ||
| 11 | 8.7 | 15.9 | 12.3 | 15.6 | ||
| Ejection fraction | 60 (55-65) | 64 (59-65) | 0.040 | — | — | — |
| Cause of death | <0.001 | |||||
| Drowning | 0.8 | 0.0 | ||||
| Drug intoxication | 5.8 | 24.3 | ||||
| Asphyxiation | 5.8 | 8.1 | ||||
| Cardiovascular | 11.9 | 8.1 | ||||
| GSW | 4.1 | 21.6 | ||||
| Blunt injury | 9.5 | 24.3 | ||||
| ICH/stroke | 21.0 | 2.7 | ||||
| Death from natural causes | 23.5 | 8.1 | ||||
| None of the above | 17.7 | 2.7 | ||||
| Ischemic CM | — | — | — | 27.82 | 37.5 | 0.224 |
| Status at transplant | 0.926 | |||||
| 1 | 9.3 | 12.5 | ||||
| 2 | 48.0 | 46.9 | ||||
| 3 | 16.1 | 9.4 | ||||
| 4 | 20.7 | 25.0 | ||||
| 5 | 0.9 | 0.0 | ||||
| 6 | 5.0 | 6.3 | ||||
| Support | ||||||
| Ventilated | 1.7 | 3.1 | 0.516 | |||
| Inotropes | 46.7 | 50.0 | 0.705 | |||
| LVAD | 24.4 | 28.1 | 0.624 | |||
| RVAD | 2.2 | 6.3 | 0.113 | |||
| ECMO | 6.4 | 9.4 | 0.489 | |||
| IABP | 29.3 | 37.5 | 0.307 | |||
| AICD | 68.2 | 75.0 | 0.409 | |||
| Comorbidities | ||||||
| eGFR | 65.3 (49.5-84.5) | 73.8 (49.0-86.7) | 0.670 | |||
| DM | 29.5 | 37.5 | 0.320 | |||
| CVD | 7.5 | 9.4 | 0.687 | |||
| PVR, dynes · sec/cm5 | 171 (112-250) | 159 (102-250) | 0.792 | |||
| Other characteristics | ||||||
| DCD | 56.4 | 8.1 | <0.001 | — | — | — |
| IVDU | 4.9 | 18.9 | 0.002 | — | — | — |
| Smoker | 14.0 | 8.1 | 0.325 | 40.8 | 46.9 | 0.488 |
| HTN | 50.2 | 51.4 | 0.897 | — | — | — |
| Malignancy | 2.9 | 2.7 | 0.952 | 1.2 | 3.1 | 0.326 |
| Any infection | 70.8 | 78.4 | 0.339 | — | — | — |
Values are n (%) or mean ± SD, unless otherwise indicated.
AAPI = Asian American Pacific Islander; AICD = implantable cardioverter-defibrillator; CM = cardiomyopathy; CVD = cerebrovascular disease; DCD = donation after circulatory death; DM = diabetes mellitus; ECMO = extracorporeal membrane oxygenation; eGFR = estimated glomerular filtration rate; GSW = gunshot wound; HTN = hypertension; IABP = intra-aortic balloon pump; ICH = intracerebral hemorrhage; IVDU = intravenous drug usage; LVAD = left ventricular assist device; NAAT = nucleic acid amplification test; PVR = pulmonary vascular resistance; RVAD = right ventricular assist device; UNOS = United Network for Organ Sharing.
The main limitation of the UNOS data set for this analysis is the lack of COVID-19 symptomatology of the donors or its temporal relation to organ retrieval; however, it remains encouraging that short-term survival was similar for recipients of organs from SARS-CoV-2 test positive and negative donors. Further investigation will be needed, especially given the expectation of the scientific community that SARS-CoV-2 eradication is unlikely and for endemic infection in some regions to persist.
The question of whether to accept hearts from SARS-CoV-2–positive donors is an important ethical dilemma that needs to be addressed promptly. As patients languish on organ waitlists without viable alternatives and thousands of new SARS-CoV-2 diagnoses are made daily in the United States alone, transplant clinicians and centers have a duty to discuss the potential risks and benefits of transplantation clearly and openly from a SARS-CoV-2 test positive donor versus the risk of continued waiting. Although active infection in a recipient of a donated non-lung organ has not been described, the immunologic and functional sequelae of prior infection remain incompletely elucidated. However, this analysis shows that acceptance of a carefully selected heart from a SARS-CoV-2 test positive donor may be safe in the short term.
Footnotes
Maria Rosa Costanzo, MD, served as the Guest Associate Editor for this paper. Barry Greenberg, MD, served as the Guest Editor in Chief for this paper.
Dr Ahmad is on the Organ Procurement and Transplantation Network Heart Transplantation Committee. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
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