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From mid-March to mid-May, heart donor recoveries and heart transplant volume both decreased by 26% nationally, compared with the early part of 2020.
COVID-19’s greatest impact on heart transplant activity was seen in the hardest-hit Northeast part of the country, but other regions, including areas with few virus patients, also experienced significant drops in transplant activity.
All parts of the United States saw decreases in donor recovery compared with pre-COVID, and only the Northwest region saw no decrease in heart transplant volumes.
During the same period, 600 patients in need of a new heart were taken off the waitlist, representing a 75% increase in inactivations compared with earlier in the year. Of this 600, 403 (67%) were reported to be because of COVID-19 precautions.
Not surprisingly, the Northeast had the most inactivations for COVID-19 (196 patients), followed by the Southwest (81 patients), and the Great Lakes (63 patients). For context, according to the United Network for Organ Sharing (UNOS), there are currently 3131 adults awaiting a heart transplant in the US.
“The numbers of patients removed from the waitlist for COVID considerations in New York didn’t surprise me, given the changes we had to make here to manage COVID-19, but the fact that we saw these decreases across most of the country, not just in transplantation but also in donor recovery, I think speaks to the fact that there is a complex interplay in broader organ sharing and the new allocation system whereby specific practice changes in certain regions have far-reaching implications for patients waiting for organs across the country,” said Ersilia DeFilippis, MD, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center in New York City.
In a study just published in JAMA Cardiology, DeFilippis and colleagues describe national and regional trends for heart transplantation, blending transplantation data from UNOS with regional figures on COVID-19 caseloads from the US Centers for Disease Control and Prevention.
Starting March 15, UNOS allowed transplant professionals to denote if their patient inactivation was due to COVID-19 precautions. Based on this, DeFilippis and colleagues considered January 19 to March 15 the pre-COVID period and March 15 to May 9 the COVID period.
DeFilippis allowed that COVID-19 was already prevalent in some communities before this date such that some “pre-COVID” inactivations might have also been due to COVID-19 but were not registered as such.
These data are not surprising to Nader Moazami, MD, surgical director of heart transplantation and mechanical circulatory support at NYU Langone Health in New York City. His program inactivated their patients and stopped doing transplants at the end of March and did not resume normal activities until late May.
“This was a very dynamic situation and there were so many logistical and clinical considerations — ICU beds, ventilators, PPE, how to test donors for COVID, the risks of COVID to transplant recipients and staff, how immunosuppressed patients might fare if they got COVID-19 — it was kind of a perfect storm and I think there was good consensus here in the New York area that we needed to just stop doing heart transplants unless it was absolutely necessary,” he told theheart.org | Medscape Cardiology.
At NYU, they went from doing three or four transplants a month, to doing no transplants but, thankfully, had no patients die. Two patients had left ventricular assist devices implanted to bridge them over this period, he shared.
“We had daily meetings and our patients were monitored very carefully using telehealth systems, such that if there was any concern that a patient might die while waiting, we would act before anything bad happened and consider other options for that patient,” said Moazami. “And we did not have even a single patient die during that time.”
DeFilippis thinks her hospital did just two or three heart transplants during this period and those were on patients who were already in-house waiting for hearts and too sick to go home.
“These were incredibly sick patients who had been waiting in the hospital for weeks to months previously, where the risk of not doing the transplant was greater than the risk of doing it,” she said.
Risk Avoidance All Around
The decrease in transplant activity does not surprise health economist Sara Machado, PhD, London School of Economics, England, who studies organ donation and transplantation.
“Organ procurement is traditionally conservative and risk averse — learned from past mistakes — so in this situation where it was very difficult to control the environment, it’s only natural to put in stops until it’s safe to proceed,” she told theheart.org | Medscape Cardiology.
The new allocation system allows organ procurement organizations to cross regional boundaries to recovery hearts for the sickest patients, but in the height of the pandemic, she said, those recoveries would be “very problematic.” Add to that the difficulty in donor testing for COVID-19 and restrictions on hospital access and travel, and many donor sites simply opted out.
“UNOS responded very quickly to the situation, which they can do because it’s a very centralized system with few decision nodes and excellent regional cooperation,” she added.
It wasn’t just clinicians who wanted to avoid risk during this period. DeFilippis also reported a 38% drop in the number of patients added to the waitlist compared with pre-COVID times, indicating that patients were also making some decisions about their care.
Said Moazami, “You have to realize, it wasn’t just us stopping transplant activity. The patients were afraid to come in, especially here in New York with so much COVID. At one point, the entire hospital was full of COVID patients, so this was the last place our heart failure patients wanted to be and we had very few patients coming for new evaluation for transplant,” he said.
He suspects that some of the excess deaths registered in New York during that period might have been patients opting out of being assessed for transplant.
“It’s interesting to me that during that phase, we weren’t even seeing the type of patients that we used to see before — patients coming in with really bad heart failure and needing therapy. I don’t know where these patients were going, but if you look at the data suggesting that the mortality in New York state was twice as much as it was the year before, not counting COVID mortality, we have to wonder if some of those patients just died,” he said.
According to UNOS, heart transplant activity has now bounced back robustly in the Northeast region but has fallen somewhat in the Southeast.
DeFilippis, Moazami, and Machado disclosed no relevant financial relationships.
JAMA Cardiol. Published online July 22, 2020. Full text