key: cord-0724500-r12zq1hx
authors: Dolores García-Cosío, M.; Hernán, Marta Flores; Pérez, Pedro Caravaca; López-Medrano, Francisco; Arribas, Fernando; Jiménez, Juan Delgado
title: Heart transplantation during the coronavirus disease 2019 pandemic: follow-up organization and characteristics of infected patients
date: 2020-09-06
journal: Rev Esp Cardiol (Engl Ed)
DOI: 10.1016/j.rec.2020.08.011
sha: 339025e9dcc5a279e96e7824d12d250ebed1c35a
doc_id: 724500
cord_uid: r12zq1hx

nan

We present our experience with heart transplant (HT) recipient care during the pandemic in Madrid (Spain). Our program has performed 614 HT procedures in the last 30 years, with patients from a wide geographical area (including the Canary Islands) regularly followed up both at our hospital (as a referral center) and at their local institutions. All information was collected from our medical records (figure 1).

During a 2-month period (February 28 to April 28, 2020), all HT recipients were screened for COVID-19 symptoms. All recipients received information about the confinement and protective measures (face mask and hand hygiene) and about the procedure to be followed in the case of suspected COVID-19. We scheduled telephone follow-up for high-risk patients (ie, late allograft dysfunction) and deferred the visits of stable patients. We maintained visits for the most recent HT recipients (within 3 months after transplantation) in a protective circuit for outpatient care in our hospital. A coronavirus-free area called an intermediate area (IA) was established in our center to evaluate high-risk patients (solid organ transplant recipients, ventricular assist device patients, and oncologic patients) who needed evaluation due to suspected COVID-19. This IA comprised individual rooms that permitted patient evaluation, including chest X-ray and the collection of upper respiratory tract samples for coronavirus RNA detection by polymerase chain reaction (PCR) and blood samples. This IA was available 24 hours a day, 7 days a week and eliminated the need for these patients to visit the emergency department. All IA staff received intensive training in procedures concerning patient isolation, individual protective equipment management, and routine sterilization.

The clinical stage at evaluation according to a recently proposed classification 3 is shown in figure 1.

Stage I (mild) is the initial symptomatic phase, stage II (moderate) has pulmonary involvement without (IIa) and with (IIb) hypoxia due to local lung inflammation, and stage III (severe) is a systemic hyperinflammation syndrome.

Telephone follow-up was performed for 159 HT recipients. Two patients were admitted to a different institution (and required telephone consultation). We identified 15 HT recipients with a clinical picture that suggested COVID-19 and scheduled telephone calls twice a week. Of the 15, 2 were followed up by telephone in their regular residence and 13 needed complete evaluation in the hospital (12 in the IA and 1 in a different institution). Of the 12 HT recipients evaluated in the IA, 4

were sent home safely after COVID-19 was ruled out. None developed the infection in the subsequent 30 days. The remaining 8 patients tested positive and required hospitalization for monitoring and treatment.

COVID-19 was diagnosed in 13 of the 159 patients screened (8.2%; 95% confidence interval, 4-12).

Their clinical characteristics are described in table 1. Four of these patients have previously been reported. 4 Notably, 15% of the patients had leucopenia in the preceding 3 to 6 months, as described previously. 5 Nine (69%) of them received triple immunosuppressive therapy with either tacrolimus (n = 7) or cyclosporine (n = 6). None was receiving mTOR inhibitor therapy. Twelve of the patients were SARS-CoV-2 PCR-positive; the remaining patient was clinically diagnosed. In 4 patients (31%), the PCR test had to be repeated after a negative test result was obtained despite high clinical Page 3 of 11 J o u r n a l P r e -p r o o f 3 suspicion (1 patient provided 2 nasopharyngeal and 2 sputum samples before a positive result was obtained). We observed mild troponin elevation in 6 patients that was three times the cutoff value but it was not related to clinical events. Two patients developed severe leucopenia during follow-up that required granulocyte-colony stimulating factor.

The COVID-19 treatment was based on our institutional protocol, which was revised on a daily basis. We discontinued calcineurin inhibitors in 6 patients (in the 5 stage III patients and when lopinavir/ritonavir was prescribed in 1).

All 3 stage I patients remained uneventful. Three patients had a bimodal course with recurrence of symptoms and elevated inflammatory markers before definitive improvement was achieved. Four patients (31%) died; all had stage III disease at diagnosis. 3 The causes of death were respiratory failure (2 patients), bacterial infection (1 patient), and hemorrhagic shock due to retroperitoneal hematoma attributable to low-molecular-weight heparin (1 patient).

The incidence of COVID-19 infection in our HT population was 8%, despite the indication of intensive protective measures for this high-risk population. This incidence is higher than that a Time from symptom onset to outcome assessment.

Venn diagram of the HT population included in the study and the main associated outcomes. HT, heart transplant. * Bimodal: recurrence of symptoms and inflammatory markers before definitive improvement.

Epidemiological and clinical characteristics of 99 cases of

China: a descriptive study

Clinical characteristics of coronavirus disease 2019 in China

COVID-19 illness in native and immunosuppressed states: a clinicaltherapeutic staging proposal

COVID-19 in solid organ transplant recipients: a single-center case series from Spain

Epidemiologic and clinical characteristics of heart transplant recipients during the 2019 coronavirus outbreak in Wuhan, China: a descriptive survey report

Updated information on coronavirus disease in Spain is provided by the Spanish Government