Conclusion
Situated in a SARS-COV-2 epicenter, our academic medical center
designated all intensive care units as SARS-COV-2 units, except the
cardiovascular unit (CVICU). Both patients were admitted to CVICU given
their circulatory support requirements.
No-visitor policies were implemented, and employees were instructed to
self-monitor for SARS-COV-2 symptoms. A single provider was appointed as
the contact for each patient to reduce total contacts, especially
perioperatively when patients are maximally immunosuppressed.
New Jersey’s Stay-At-Home order and recommendation against elective
surgery likely aided in our center’s ability to provide judicious
emergent care, including care for patients in decompensated heart
failure awaiting transplant. Under similar conditions, Hsu et al.in Los Angeles performed eight successful heart transplants at the
University of California early in the pandemic.4
Regarding donor-to-recipient transmission risk, donor institutions
confirmed SARS-CoV-2 negativity in both cases. Organ procurement was
limited to single surgeon/restricted geographic radius. Besides
utilizing more personal protective equipment intraoperatively, usual
operative protocols were unchanged.
Postoperatively, both patients were transported to CVICU along
designated SARS-CoV-2-negative pathways; Boffini et al. described
comparable measures.6 We considered the risks of
standard perioperative immunosuppression, i.e. , calcineurin and
inosine-5’-monophosphate dehydrogenase inhibitors preventing T
lymphocyte proliferation and thereby downregulating the body’s defense
against viruses like SARS-CoV-2. However, so too could immunosuppression
diminish the susceptibility of heart recipients to inflammatory sequelae
characteristic of SARS-CoV-2 infection. Thus, we elected to proceed with
standard immunosuppression accompanied by serial myocardial biopsies to
monitor for graft rejection. Patient education regarding self-quarantine
and avoidance of infection risks supplemented usual institutional
protocol. Consistent with our practice, current recommendations dictate
continuation of standard immunosuppression with usual postoperative
surveillance.6,7 No change was made to
immunosuppression upon our Case 1 patient’s seropositivity at two months
post-transplant.
Concern of the morbidity of postoperative SARS-COV-2 has been a topic of
consideration. An 87-patient study in China reported post-transplant
patients experiencing virus-related morbidities comparable to those in
the general population.4-6 In our study, one patient
was transiently seropositive at two months post-transplant but was
asymptomatic throughout the following eight months. This suggests that
patients transplanted during the pandemic may be at no greater risk than
the general population throughout their perioperative
course.1,3,5 Even with these reassuring outcomes,
minimal U.S. investigation begs further study.
At our academic medical center, interdisciplinary care coordination
continues to minimize SARS-CoV-2 exposure risk. During a single visit,
our heart recipients see their surgeon and cardiologist, and undergo
myocardial biopsy. Telemedicine is also integrated into patient
follow-up care, similar to Hsu et al .5
SARS-CoV-2 continues to challenge hospital systems globally. Reflecting
on early pandemic experience, we demonstrate that intentional recipient,
donor, and provider testing, cautious organ procurement, strategic
intrahospital patient organization and transport, and well-coordinated
follow-up may permit uninterrupted provision of definitive therapy for
advanced stage heart failure without placing these patients at greater
risk.