Breakthrough COVID-19 Infections in Heart Transplant Recipients: A Case Series

PURPOSE: Heart transplant (HT) recipients are at high risk for Covid-19 infection, and data are limited about the efficacy of vaccination in this unique population. We sought to describe the presentation and outcomes of a cohort of HT patients with Covid-19 infection despite prior vaccination. METHODS: Retrospective chart review of 250 adult HT recipients followed at the University of Southern California identified 7 individuals with PCR-proven Covid-19 infection after full vaccination (no patients received booster doses) between December 1(st), 2020 and October 1(st), 2021. Baseline clinical characteristics, serial echocardiographic parameters, laboratory testing, medication regimens, clinical presentation and clinical course were collected. RESULTS: A total of 237 were vaccinated with an incidence of 7 breakthrough infections (3%). Patients were predominantly male (71%) with a median age of 50 years old. The average BMI was 32.89. Hypertension (86%), diabetes (57%), and hyperlipidemia (43%) were common. Nearly all (71%) of patients were on 3 classes of immunosuppressive therapy, and nearly half (43%) had a history of rejection. Five patients (72%) received Pfizer-BioNTech, 1 patient (14%) received Moderna, and 1 patient (14%) received the Johnson & Johnson vaccination. One patient had a prior history of Covid-19 infection before vaccine availability. Patients were on average 6.74 (3.8-8.4) years out from transplantation. The most common presentation was dyspnea (71%), cough (57%), and fever (43%). Seventy one percent were hospitalized, and 29% were admitted to the ICU. Treatments varied, with equal rates of antibiotics (29%), steroids (29%), and remdesevir (29%). However the most common treatment was monoclonal antibody therapy (57%). One patient, vaccinated with a single Johnson & Johnson shot, died lending an 86% survival rate for breakthrough infections after Covid-19 vaccination. CONCLUSION: In a single center experience 7 patients with a history of heart transplant and breakthrough Covid-19 infection were identified and found to have an 86% survival rate. Further investigation is needed assessing the efficacy of the Covid-19 vaccination in this population, as well as evaluation for differential outcomes between the various vaccine options.