Use of Remdesivir to Treat COVID-19 after Orthotopic Heart Transplant

PURPOSE: Guidance for managing orthotopic heart transplant (OHT) recipients with COVID-19 infection is limited. There have been 80 published cases of OHT recipients with COVID-19 infection to date, and they show a higher incidence of infection and greater mortality (26-41%) than that observed in the general population. Remdesivir, an inhibitor of viral RNA-dependent RNA polymerase, decreases median recovery time from infection in the general population, but was not used in any OHT patients. We sought to determine the effectiveness of remdesivir to treat COVID-19 in OHT recipients. METHODS: Out of 400 OHT patients followed at UCSD, 1.8% (n=7) have tested positive for COVID-19. Four of these patients were treated with remdesivir. Three patients with milder symptoms did not require treatment. RESULTS: OHT recipients with COVID-19 infection were a median 55 years of age (range 28-62 years), 71% (5/7) were male, and they were a median of 3 years post-transplant (range 2-5 years). All patients were taking tacrolimus, 85% (6/7) were also taking mycophenolate mofetil (MMF) or 14% (1/7) were taking mammalian target of rapamycin (mTOR) inhibitors. All patients had positive nasopharyngeal COVID-19 PCR and were admitted for observation. MMF and mTOR inhibitors were held on admission while tacrolimus was continued. Four patients (57%) developed hypoxia requiring supplemental oxygen or had pulmonary infiltrates on chest x ray and were treated with remdesivir. Patients received an intravenous (IV) infusion of 200 mg loading dose followed by 100 mg IV daily over 4 days (total 5 doses). Two patients were also treated with IV antibiotics for bacterial pneumonia (n=1) or urinary tract infection (n=1). Three of the four patients treated with remdesivir had complete resolution of fevers, hypoxia and symptoms after a 5-day course. The fourth patient had continued hypoxia requiring supplemental O2 therapy and received an additional 5 days of remdesivir 100 mg IV daily (10-day total course) with subsequent resolution of symptoms. No patients were intubated or admitted to intensive care and all 7 patients survived to hospital discharge and had negative COVID-19 PCR at outpatient follow up. No other COVID-19 directed therapies were used. CONCLUSION: Compared to 80 patients in prior published cases, our experience suggests that prompt administration of remdesivir improves outcomes in OHT patients with COVID-19 infection.