key: cord-0954568-759ifj3l authors: Soquet, Jerome; Rousse, Natacha; Moussa, Mouhamed; Goeminne, Celine; Deblauwe, Delphine; Vuotto, Fanny; Pontana, François; Lionet, Arnaud; Dubois, Romain; Robin, Emmanuel; Vincentelli, Andre title: Heart Retransplantation Following COVID-19 Illness in a Heart Transplant Recipient date: 2020-07-07 journal: J Heart Lung Transplant DOI: 10.1016/j.healun.2020.06.026 sha: 07100666abb1f7e100734495bba38fd4632a44d7 doc_id: 954568 cord_uid: 759ifj3l nan In November 2018, a 22-year-old woman underwent successful heart transplantation (HT) for giant cell myocarditis and subsequently presented with pericardial constriction and a subdiaphragmatic mass around the inferior vena cava in December 2019. A pericardectomy was performed. Biopsies of the subdiaphragmatic mass revealed an Ebstein Barr Virus-induced lymphoma, which was treated with rituximab and reduced immunosuppression (Table) . In March 2020, during the Covid-19 pandemic, the patient was readmitted for abdominal pain and vomiting. Both tracheal and nasal swab PCR tests were positive for SARS-CoV-2 infection. Chest CT-scan showed a right-sided pleural effusion. Severe biventricular dysfunction was found but endomyocardial biopsy ruled out acute humoral rejection. The allograft function continued to deteriorate and acute rejection was suspected, therefore methylprednisolone and rabbit antithymocyte globulin (rATG) were administered. Shortly after, CT-scan showed onset of a severe pulmonary Covid-19 infection. Subsequently, an antiretroviral treatment (lopinavir/ritonavir) was introduced. Despite these therapies, the patient's condition worsened, requiring veno-arterial ECMO support. The patient was extubated 16 days later as the pulmonary insult regressed, however no cardiac recovery was observed. The patient was therefore compassionately registered on the waitlist for an emergent HT. At that time, the nasal swab was still PCR positive. A heart from a marginal donor was proposed, for which no other recipient was found in France mainly due to size mismatch. The graft was managed with the Organ Care System (TransMedics, Andover, MA, USA) because: 1)the donor was marginal, 2)the duration of the travel was long (3 hours) and 3)we expected technical difficulties removing the first heart graft due to the 2 previous sternotomies. The perfusion time under the Organ Care System was 370 minutes. Heart retransplantation was uneventful and cardiopulmonary bypass was successfully weaned after 199 minutes, with low dose dobutamine. Hemoadsorption with CytoSorb (CytoSorbents Europe GmbH, Berlin, Germany) was used during cardiopulmonary bypass in order to modulate cytokine activation. The patient was extubated a week later. She was still SARS-CoV-2 PCR positive on the day of ICU discharge, with a normal chest X-ray. The patient was discharged home after rehabilitation at postoperative day 44, although still PCR positive. Histologic examination of the former graft revealed a chronic rejection process. Of note, the SARS-CoV-2 serology tests were negative during the entire hospital stay. We did not measure direct virial activity or viral loads. Chen et al. reported 3 cases of lung transplantation for SARS-CoV-2-related pulmonary fibrosis, but in PCR negative patients(1). We present a cardiac transplant in the recovery phase of COVID-19 but with evidence of persistent SARS-CoV-2 positivity on PCR testing. Our team considered the young age of the patient for registration on the waitlist for HT and determined that it was ethical since we chose a donor that would not have been otherwise used (2) . To date, the rationale for the use of an organ from a SARS-CoV-2 positive donor remains controversial (3, 4) . The optimal pharmacological management of HT in Covid-19 recipients is yet to be defined. At the time of retransplantation, it was decided to avoid induction and to use higher doses of immunosuppressive drugs (Table) . The patient's chronic immunosuppressive status may have given her better chance by avoiding COVID-19 cytokine storm. However, we suspect that rATG may have triggered the pulmonary form of the coronavirus infection and resulted in the initial deterioration. Department of Cardiac Surgery Department of Anesthesia and Intensive Care Department of Infectious Diseases, F-59000 Department of Cardiovascular Imaging, F-59000 Lille, France 5 Lung transplantation as therapeutic option in acute respiratory distress syndrome for COVID-19-related pulmonary fibrosis Ethical considerations regarding heart and lung transplantation and mechanical circulatory support during the COVID-19 pandemic: an ISHLT COVID-19 Task Force statement Utilization of deceased donors during a pandemic: An argument against using SARS-CoV-2 positive donors The authors would like to thank the staff and nurses who provided care for the patient; and Ms.Stephanie Brumby for her editing assistance.