Conclusion
Situated in a SARS-COV-2 epicenter, our academic medical center designated all intensive care units as SARS-COV-2 units, except the cardiovascular unit (CVICU). Both patients were admitted to CVICU given their circulatory support requirements. No-visitor policies were implemented, and employees were instructed to self-monitor for SARS-COV-2 symptoms. A single provider was appointed as the contact for each patient to reduce total contacts, especially perioperatively when patients are maximally immunosuppressed.
New Jersey’s Stay-At-Home order and recommendation against elective surgery likely aided in our center’s ability to provide judicious emergent care, including care for patients in decompensated heart failure awaiting transplant. Under similar conditions, Hsu et al.in Los Angeles performed eight successful heart transplants at the University of California early in the pandemic.4
Regarding donor-to-recipient transmission risk, donor institutions confirmed SARS-CoV-2 negativity in both cases. Organ procurement was limited to single surgeon/restricted geographic radius. Besides utilizing more personal protective equipment intraoperatively, usual operative protocols were unchanged.
Postoperatively, both patients were transported to CVICU along designated SARS-CoV-2-negative pathways; Boffini et al. described comparable measures.6 We considered the risks of standard perioperative immunosuppression, i.e. , calcineurin and inosine-5’-monophosphate dehydrogenase inhibitors preventing T lymphocyte proliferation and thereby downregulating the body’s defense against viruses like SARS-CoV-2. However, so too could immunosuppression diminish the susceptibility of heart recipients to inflammatory sequelae characteristic of SARS-CoV-2 infection. Thus, we elected to proceed with standard immunosuppression accompanied by serial myocardial biopsies to monitor for graft rejection. Patient education regarding self-quarantine and avoidance of infection risks supplemented usual institutional protocol. Consistent with our practice, current recommendations dictate continuation of standard immunosuppression with usual postoperative surveillance.6,7 No change was made to immunosuppression upon our Case 1 patient’s seropositivity at two months post-transplant.
Concern of the morbidity of postoperative SARS-COV-2 has been a topic of consideration. An 87-patient study in China reported post-transplant patients experiencing virus-related morbidities comparable to those in the general population.4-6 In our study, one patient was transiently seropositive at two months post-transplant but was asymptomatic throughout the following eight months. This suggests that patients transplanted during the pandemic may be at no greater risk than the general population throughout their perioperative course.1,3,5 Even with these reassuring outcomes, minimal U.S. investigation begs further study.
At our academic medical center, interdisciplinary care coordination continues to minimize SARS-CoV-2 exposure risk. During a single visit, our heart recipients see their surgeon and cardiologist, and undergo myocardial biopsy. Telemedicine is also integrated into patient follow-up care, similar to Hsu et al .5
SARS-CoV-2 continues to challenge hospital systems globally. Reflecting on early pandemic experience, we demonstrate that intentional recipient, donor, and provider testing, cautious organ procurement, strategic intrahospital patient organization and transport, and well-coordinated follow-up may permit uninterrupted provision of definitive therapy for advanced stage heart failure without placing these patients at greater risk.