May 23, 2023 – People who receive a heart transplant from a donor who had active COVID-19 have a higher risk of dying at 6 months and 1 year after, compared to those who receive a heart from patients without COVID, new research has found.
"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," lead investigator Shivank Madan, MD, a cardiologist at the Center for Advanced Cardiac Therapy at Montefiore Medical Center/Albert Einstein College of Medicine in New York City, said in a statement.
The study was published online May 17 in the Journal of the American College of Cardiology.
COVID can cause early signs of heart disease and damage to the heart in potential donors. Currently, there is no clear consensus on the evaluation and use of COVID-19 donors for heart transplants.
Prior data from two small studies suggested similar short-term results among patients who received hearts from donors who had COVID and from those who didn't.
For this analysis, the researchers identified 27,862 donors in the United Network for Organ Sharing (UNOS) database, between May 2020 and June 2022, who had undergone nearly 61,000 highly sensitive and accurate tests for COVID.
Donors were considered COVID donors if they tested positive at any time during their hospital stay. Active COVID status was given to those who tested positive within 2 days of when the organ was harvested, and recently resolved COVID status was given to those who tested positive at first but became negative before heart donation.
Of the 1,445 COVID donors, 1,017 were classified as active cases and 428 as recently resolved. Overall, 239 adult heart transplants met the criteria for the study (150 with an active infection and 89 with a recently resolved one).
Heart transplants from an active COVID-19 donor were linked to a higher risk of death at 6 months and 1 year, compared to heart transplantation from a non-COVID donor.
Death rates at 6 months and 1 year were 13.8% and 23.2%, respectively, for those who received active COVID-19 donor hearts versus 7% and 9.2%, respectively, for those who received non-COVID-19 donor hearts.
Death rates at 6 months and 1 year were similar for heart transplants from recently recovered and non-COVID donors.
Calls for Caution and More Data
"The current study highlights the importance of continued evaluation and probably the need for a more nuanced approach towards utilizing this new donor pool," the researchers said.
"Further studies of larger numbers of patients, longer follow-up, and more detailed clinical data are needed to assess the outcomes of [heart transplants] from COVID-19 infected donors," they said.
Sean Pinney, MD, chief of cardiology at Mount Sinai Morningside in New York City, said this "carefully performed analysis raises a note of caution about accepting hearts from donors with active or recent COVID-19."
He agrees with the researchers that more research is still needed. "While there appears to be a signal of harm, I think it unwise to draw too many conclusions from the data as they are presented. This analysis is unable to provide details about the mechanisms which might explain the observed increase in mortality," Pinney said.
"It is curious that a signal for harm does not appear until more than 3 months after transplant. Furthermore, we do not know the immunization status of these recipients and how vaccination may impact outcomes," he said.
Heart transplant programs should continue to carefully weigh the pros and cons of using these donor organs, "keeping in mind that transplant candidates who remain on the list face a very high chance of dying. Using a carefully selected organ from a COVID-19 patient may still be in their best interest," Pinney said.
Alex Reyentovich, MD, medical director of the heart transplant program at NYU Langone Heart, cautioned that the study lacks "granular" data on the amount of virus in the COVID donors.
A donor could have higher or lower levels of virus in their system, but "this study does not get into that level of [detail]," he said.
"A donor with an active COVID infection is someone that none of us would probably take. But someone with a positive COVID test and a very low [amount of virus], that is someone that I think most centers would take," Reyentovich said.
"Hopefully, in the future, this will become less and less of an issue and we can stop making these types of decisions," he said.