key: cord-0994507-98rmx8lx authors: Kuczaj, Agnieszka; Przybyłowski, Piotr title: Patients after orthotopic heart transplantation with COVID-19-are we fast enough with vaccinations? date: 2022-03-15 journal: Transplant Proc DOI: 10.1016/j.transproceed.2022.02.022 sha: d371f3e1593d03dc9e9c24b34b93f70d5b73b280 doc_id: 994507 cord_uid: 98rmx8lx Background: Patient after orthotopic heart transplantation (HTx) are especially susceptible to infections due to permanent need for immunosuppression. Since January 2021 vaccinations against COVID-19 are available and recommended in organ recipients. Aim: to analyze COVID-19 susceptibility and mortality in HTx and number of patients with COVID-19 previously vaccinated against SARS-CoV-2. Patients and methods: we analyzed whole cohort of patients after HTx who were SARS-CoV-2 positive among 552 patients remaining under surveillance of the transplantation center; timeframe: March 2020 – September 2021. Results among 552 patients after heart transplantation, 10 were COVID-19 survivors prior to transplantation, 103 had SARS CoV-2 infection after transplantation. Mean age of COVID-19 infected patients was 55.6 (±14) years, mean time from transplantation to SARS-CoV-2 infection was 2856 (±2596) days, range 16-9569 days, IQR 397-4763 days. 2856 (±2596) days. Among the infected patients 15 were asymptomatic, 10 died, 51 infections occurred in the era of vaccinations. In the group of patients positive in 2021, 6 received only single dose of the mRNA vaccine, 3 were vaccinated twice. Among the vaccinated patients with COVID-19 two died due to severe form of COVID-19: one after single dose and one after two standard doses of the vaccine. Conclusion: we observed high susceptibility to SARS-CoV-2 infection in the group of patients after HTx. The majority of patients infected in 2021 did not received the vaccine. Vaccination do not fully protect against severe form of COVID-19 in the patients after HTx. The figures may be printed in black and white According to current ISHLT guidelines [1] all patients after solid organ transplantation (SOT) should receive vaccination against SARS-CoV-2 infection. The optimal timing for the vaccination is at least one month after transplantation, 3-6 months after induction or lymphodepletion therapy or at least one month after rejection treatment with high doses of steroids. In Poland we have wide access to SARS-CoV-2 vaccines: available are two recombinant nonreplicating viral vector vaccines (Ad26.COV2-S, ChAdOx1-S) and two mRNA vaccines. The vaccinations in our country are accessible since January 2021. Observations performed in the general population showed, that the vaccines reduce occurrence of the infection, and severity of the disease [2] [3] [4] . Furthermore, many studies confirmed the safety and efficacy of the vaccination in subpopulation of transplant recipients [5, 6] . There are no cut-off values for vaccination efficacy. However, it seems that antibody titer needed to prevent severe infection in solid organ recipients is lower than the titer necessary to fully prevent the infection [6, 7] . There is also possibility, that after vaccination the patients develop parallelly cellular immunity, that can be present also in the absence of vaccination induced antibodies [8] Aim of the study: Assessment of vaccinations efforts in patients after heart transplantations in a single heart transplant center and evaluation of morbidity and mortality due to SARS-CoV-2 infection in this group of patients. Single center prospective observational study in adult patients after heart transplantation. The whole Since January 2021 to September 2021, in the era of vaccinations, we noted 51 infections (Fig. 2) . In the patients infected in 2021 only 3 (5.9%) were fully vaccinated (two doses of mRNA vaccine). Among the infected patients 6 pts (11.8%) were partially vaccinated (after single dose of two-dose mRNA vaccine). In the group of previously vaccinated patients, two dyed due to SARS-CoV-2 infection: one patient after two doses of mRNA vaccine (fully vaccinated) and one patient after single June 2020 showed 33.3% mortality due to COVID-19 [9] , in the Italian heart transplant population, the mortality was almost 30% [10] . Efforts are made to prevent Polish population from the SARS-CoV-2 pandemic and their consequences. One of the best large-scale preventive measures in case of highly contagious infective diseases is vaccination. For the immunocompromised patients with weakened immune response advised are not only immunizations of these patients, but also immunizations of their caregivers and people from their home environment. Unfortunately, only less than 50% [11] of general Polish population, despite wide accessibility and known efficacy in reducing the incidence and severity of the disease, received the vaccine. Low percentage of vaccinated people in population is disadvantageous for this group of patients. Despite this situation, we see efforts of our work: encouraging to vaccinations we achieved much higher percentage of vaccinated persons in our transplant group (79,7%), when compared to general population. These results are comparable with USA transplant centers, with vaccination rate about 70% [5] Our data show lower incidence of SARS-CoV -2 infection in vaccinated patients when compared to unvaccinated patients. The infected patients were mainly unvaccinated (94% of heart transplant recipients with COVID-19 in 2021). It stays in line with results obtained from a large cohort of solid organ transplant (renal, heart, lung, liver) recipients from USA. They showed almost 80% calculated reduction in COVID-19 susceptibility when compared to non-immunized group [5] . In our population we cannot reliably perform such calculation and estimate how many patients benefited from the immunization, as did these authors. The third wave of COVID-19 pandemic in Poland started parallelly with vaccinations of investigated population. Hence, this situation could be interpreted in two ways: the vaccination protected from the infection or the pandemic was giving up and the chance of exposition to the virus was lower. Probably, such kind of calculation will be reasonably and can take place after the fourth wave of the pandemic. As suggested by other authors, vaccination itself does not prevent from severe form of COVID-19 and we observed severe course of the disease after full course of the vaccination. For the protection necessary is adequate humoral and/or cellular response to the vaccination [12] . Diabetes, older age, high maintenance immunosuppression and lowered eGFR are predictors of weakened response to the vaccination [13, 14] . Simultaneously, these factors are markers of poorer outcome in general population in case of COVID-19 infection. We think, that in the group of HTx recipients, routine two vaccine doses with booster dose is not enough what we can do for these patients. Immunity against the infection is connected with the level of circulating neutralizing antibodies. Schemes of follow-ups after the vaccination with assessment of humoral (more accessible) or cellular response are urgently needed, however the protective levels are still being assessed [15] . Temporary modification of immunosuppressive regime during buster vaccination in non-responders might also be considered. We observed high susceptibility to COVID-19 in heart transplant patients. 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