Challenges in Heart Transplantation in COVID 19 Pandemic New Biopsy Protocol a Single Center Experience

PURPOSE: Orthotopic heart transplantation remains the treatment of choice for endstage heart failure. In the face of the COVID19 pandemic, managing patients with advance HF before and after OHT has become an increasing challenge in both: in immunosuppression treatment and postoperative managements including biopsy protocol METHODS: We retrospectively evaluated the outcomes of all patients who underwent OTH from March 2020 to February 2021 at Silesian Heart Diseases Center, Zabrze, Poland. Due to global pandemic of COVID19 several challenges including reduced numbers of myocardial biopsies were done RESULTS: 88 patients (67 male, 21 female) underwent OHT. During this period of time the COVID-19 infections were at high level in Poland. Both donor and recipients were tested for SARSCOV2 within 48 hrs of the procedure and none tested positive. We employed strict protocol of hand hygiene, PPE usage, isolation and regular staff PCR testing. We elected to reduce the routine myocardial biopsy rate from 4to1 in first month in order to reduce exposure of the patients to the potential of COVID19 disease. All patients received a standard triple regimen of calcineurin inhibitor (tacrolimus), antimetabolite (mycophenolate mofetil) and methylprednisolone. The level of immunosuppressive medications was done every day. 20 of 88 patients underwent first biopsy at 7 - 10 days post-operatively, and 3 more biopsies at one-month interval. The first myocardial biopsies did not demonstrate acute cellular rejection. We observed acute cellular rejection (2R grade) among 3 patients (15%) in second myocardial biopsy and they were treated with methylprednisolone 1gram iv for 3 days and after we return to previous prednisone dose. Third myocardial biopsy did not demonstrated acute cellular rejection. All of patients were discharged from the hospital at day14 days, and followed up in OPD once a week till the next admission. Ultrasonography including strain echo parameters of left and right ventricle, lab tests and the level of immunosuppression were done during each OPD visit. CONCLUSION: OHT recipients who underwent reduced numbers of myocardial biopsies appear to have reasonable outcomes (including adequate home support) compared to recipients with standard protocol. We have shown that successful heart transplantation could be performed during of COVID19 disease pandemic.