key: cord-1022469-rcmz1qzq authors: Hardman, Gillian; Sutcliffe, Ruth; Hogg, Rachel; Mumford, Lisa; Grocott, Laura; Jerrett, Lorraine; Mead‐Regan, Sarah‐Jane; Nuttall, Jane; Dunn, Stephanie; Seeley, Philip; Quigley, Richard; Dalzell, Johnathan R.; Al‐Attar, Nawwar; Parameshwar, Jayan; Fisher, Andrew J.; Booth, Karen; Dark, John H. title: Heart transplantation in the UK during the first wave of the SARS‐CoV‐2 pandemic date: 2021-03-09 journal: Clin Transplant DOI: 10.1111/ctr.14261 sha: d51a0212673625facb5a63ab248e2ccf87db8047 doc_id: 1022469 cord_uid: rcmz1qzq BACKGROUND: We aim to evaluate practice and understand the impact of the first wave of the SARS‐CoV‐2 pandemic on heart transplantation in the UK. METHODS: A retrospective review of the UK Transplant Registry (UKTR) and a national survey of UK heart transplant centers have been performed. The early pandemic period is defined here as 1 March to 31 May 2020. RESULTS: There was geographic variation in the prevalence of COVID‐19 across the UK. All centers reported adaptations to maintain the safety of their staff, candidate, and recipient populations. The number of donors fell by 31% during the early pandemic period. Heart utilization increased to 35%, compared to 26% during the same period of 2019. The number of heart transplants was well maintained, across all centers, with 38 performed, compared to 41 during the same period of 2019, with no change in 30‐day survival. Twenty‐seven heart transplant recipients with confirmed COVID‐19 infection were reported during the study period. CONCLUSION: All UK heart transplant centers have successfully adapted their programs to overcome the challenges of staff redeployment and ICU and hospital resource limitation, associated with the pandemic, whilst continuing heart transplant activity. On‐going evaluation of practice changes, with sharing of lessons learned, is required as the pandemic continues. patients, maintaining the safety of this patient population becomes increasingly challenging. Transplanting these patients must also be balanced with the risk of COVID-19 in the early post-transplant period and its' potential impact on outcomes. 5 Cardiovascular manifestations of COVID-19 are reported 6 and specific concerns about the risk and severity of illness in the early post-operative period, when the burden of immunosuppression is greatest, have been raised. In addition to balancing the risks of deterioration of heart failure and COVID-19 infection, the ability of a center to maintain heart transplant activity, during the pandemic, is dictated by the availability and safety of deceased organ donors, and hospital resource, including intensive care unit (ICU) capacity and appropriate staff. Early reports from heart transplant programs globally have highlighted a significant decrease in organ donation and heart transplant activity during the pandemic. 7 Although the challenges for solid heart transplantation outlined here are well recognized, 8 there is limited published data on the national and regional changes to clinical practice, during this time. The aim of this study was to understand the impact of the first wave of the SARS-CoV-2 pandemic on heart transplantation in the UK. All adult and pediatric heart transplant centers in the UK were included in the study. Analysis included all adult (aged 16 years and older) and pediatric organ donors, heart transplant waiting list candidates and heart transplant recipients. A retrospective review of data submitted to the UK Transplant Registry (UKTR) from 1 January 2019 to 30 June 2020 was performed. The early pandemic period is defined here as 1 March to 31 May 2020. Month-to-month and center-level variation in practice were reviewed from 1 January to 30 June 2020, to include the early pandemic period, and, where appropriate, compared to data from 1 January to 30 June 2019. Eligible, potential heart donors are defined as those aged less than 65 years, with no absolute contra-indications to organ donation. Heart utilization was calculated as number of donors transplanted from the number of donors (who donated at least 1 solid organ) from whom the heart was offered for transplantation. To explore regional, center-level variation in clinical practice and policy, during the pandemic, a national survey of UK transplant centers was performed. change in 30-day survival. Twenty-seven heart transplant recipients with confirmed COVID-19 infection were reported during the study period. Conclusion: All UK heart transplant centers have successfully adapted their programs to overcome the challenges of staff redeployment and ICU and hospital resource limitation, associated with the pandemic, whilst continuing heart transplant activity. Ongoing evaluation of practice changes, with sharing of lessons learned, is required as the pandemic continues. Coronavirus pandemic, COVID-19, Heart transplantation, organ donation, SARS-CoV-2 The survey was developed using an iterative process, to identify changes in heart transplantation clinical practice, including candidate assessment, recipient management, organ donation and activity, perceptions of the prevalence of COVID-19 locally, and the impact of the transplant workforce and hospital resource. The final survey was approved following review from members of the NHSBT Cardiothoracic Advisory Group Clinical Audit Group (CTAG CAG). The NHS England Coronavirus specialty guide cardiothoracic escalation framework 9 was used to define phases in response to the pandemic. The survey return rate was 100%. Additional information and clarification of responses were performed by telephone interview with 3 of 7 UK heart transplant centers. Movement of each center through the pandemic phases is shown in Table 1 . At the time of the survey, all centers considered themselves to be moving into the recovery phase; however, a date for return to "normal" (pre-pandemic) service had not been identified in any center. All centers recognized that changes to clinical practice, adopted during the pandemic, would persist. During the early pandemic period, the number of deceased donors, who donated at least 1 solid organ, where the heart was offered for transplantation, fell by 31%, from 159 in March to May 2019 to 109 in the same period of 2020. The characteristics of donors, from whom the heart was offered, during the early pandemic period, compared to those from the same period of 2019, are shown in Table 2 . During the early pandemic period, there was a significant decrease in donor age (from a median age of 47 years in 2019 to 40 years during the early pandemic period, P =.0039) and the proportion of donors with a history of hypertension (31% in 2019 to 10% during the early pandemic period, P =.0002). In the early pandemic period, hearts from 38 donors were implanted, a utilization rate of 35%. In March to May 2019, 42 UK donors were utilized for heart transplantation (39 heart-only recipients and 3 heart-lung recipients), a utilization rate of 26% (Table 3 ). Survey participants reported that, where donor offers were received, they were confident that the risk of COVID-19 in the donor was low, as a result of national policy for donor testing. In addition to national guidance for solid-organ donation, reducing donor age limit for DBD to less than 60 years and DCD less than 50 years, in survey responses, all centers describe center-level changes In survey responses, all centers describe changes to practice to maintain social distancing and the safety of retrieval team members. These There was no significant difference in the proportion of pediatric donors offered for heart transplantation, during the early pandemic period (6.4%), compared to the same period of 2019 (4%, P =.4827). There was an increase in the proportion of pediatric recipients transplanted during the early pandemic, 26% compared to 10% during the same period of 2019, although this did not reach statistical significance (P =.0772). Of the 2 UK pediatric heart transplant centers, 80% of the early pandemic period activity was focused in 1 center. Mechanical circulatory support use, by type/indication, by month of the early pandemic period, compared to 2019, is shown in Table 5 . The number of new registrations to the heart transplant waiting list, by urgency, is shown in Table 6 . In survey responses, all but essential transplant assessments were suspended, in all centers, at the start of the early pandemic period. As centers moved through the phases of the pandemic, transplant assessment began, at reduced capacity, with reduced inpatient stay, to facilitate social distancing. One center (pediatric) reported the use of online platforms for virtual transplant assessment. This facilitated the re-starting of transplant assessment, earlier. Respondents from this center indicated that they intend to continue this method of transplant assessment, reducing travel and hospital attendance for patients and families. The outcome for patients on the heart transplant waiting list during the early pandemic period, compared to 2019, is shown in Table 7 . Confirmed COVID-19 infection was reported in 9 candidates during the study period. All centers reported that active efforts had been made to reduce hos- guidance placed restrictions on donor age, limiting DBD to age less than 60 years. Pre-COVID, the upper age limit for DBD heart donors in the UK was 65 years. These restrictions were gradually lifted between April and June 2020 and have not been re-implemented as the pandemic has continued. As a result, the number of deceased donors from whom the heart was offered for transplantation fell by 31%, All UK heart transplant centers have successfully adapted their programs to overcome the challenges of staff sickness, redeployment, and resource limitation, associated with the SARS-CoV-2 pandemic, successfully maintaining activity, during this time. Changes to outpatient follow-up and monitoring have been reported in the survey and mirror those adopted in other transplant programs. 18 The positive impact of some of these changes has been noted and measures to maintain social distancing, reduced hospital attendance, and technology-enhanced communication are continuing. This early pandemic period has been followed by a second wave of COVID-19 cases and it is increasingly evident that the SARS-CoV-2 pandemic will continue, with lasting effects on health and social care and the economy. As the number of COVID-19 cases again declines, it is important to consider the backlog of elective and non-urgent patients, and the subsequent pressure this will inflict on the healthcare service. To facilitate on-going transplant activity, some protection must be offered to our ICU and staff resource. The approval of the first vaccine against the virus will, it is hoped, protect patients, their families, and healthcare workers, The data that support the findings of this study are available from the corresponding author upon reasonable request. https://orcid.org/0000-0001-9600-4097 Coronavirus (COVID-19) in th UK. 2020 Coronavirus (COVID-19) in the UK 2020 COVID-19: Advice for Clinicians COVID-19 in recent heart transplant recipients: Clinicopathologic features and early outcomes SARS-CoV-2 Infection and Cardiovascular Disease: COVID-19 Heart Trends in US Heart Transplant Waitlist Activity and Volume During the Coronavirus Disease 2019 (COVID-19) Pandemic Challenges in Heart Transplantation in the Era of COVID-19 Coronavirus Specialty guides -management of Cardiothoracic surgery patients 2020 Elective surgery during COVID-19 2020 POL304/2 -SARS-CoV-2 Assessment and screening in Organ Donors and Recipients Successful double-lung transplantation from a donor previously infected with SARS-CoV-2. The Lancet Respiratory Medicine SARS-CoV-2 infection and early mortality of wait-listed and solid organ transplant recipients in England: a national cohort study Characteristics and Outcomes of Recipients of Heart Transplant With Coronavirus Disease COVID-19 among heart transplant recipients in Germany: a multicenter survey Impact of SARS-CoV-2 outbreak on heart and lung transplant: A patient-perspective survey Changes in Care Delivery for Patients With Heart Failure During the COVID-19 Pandemic: Results of a Multicenter Survey Heart transplantation in the UK during the first wave of the SARS-CoV-2 pandemic