Successful Heart Transplantation Following COVID-19 Infection

INTRODUCTION: With COVID-19 rampant within the heart transplant community, more direction regarding the management of these patients is needed. Case studies have described treatment of heart transplant recipients who contracted COVID-19 but no recommendations exist on management of recent COVID-19 infection in the peri-operative transplant period. CASE PRESENTATION: We describe a 47-year-old Caucasian female with nonischemic dilated cardiomyopathy diagnosed in 2003 presumed to be secondary to postpartum cardiomyopathy versus doxorubicin toxicity for the treatment of non-Hodgkin lymphoma diagnosed in 2000. Other co-morbidities include bone marrow transplantation, chest radiation, hypothyroidism, and recent COVID-19 upper respiratory infection without complications and not requiring hospitalization in December 2020. Given progressive clinical decline from her cardiomyopathy, she was admitted and underwent orthotopic heart transplantation on February 5, 2021. Immunosuppression was followed per our institution's protocol and induction therapy was completed with basiliximab. SARS coronavirus-2 spike antibody was checked prior to transplantation on February 5 (47 U/mL; reference <0.8) and decreased to 19 U/mL on February 9 after immunosuppressive therapy. At our institution, actively infected patients with COVID-19 and a spike antibody <80 U/mL are considered for convalescent plasma administration. After multidisciplinary discussion with the patient and given the limited evidence available at the time, the patient opted not to receive this unless she became symptomatic from reactivation of a COVID infection.Post-transplantation, she remained asymptomatic without clinical suspicion for reactivation. Regular endomyocardial biopsies have been performed per our institution protocol with SARS coronavirus-2 PCR testing prior to presentation and have remained undetected. Biopsies have not shown evidence of allograft rejection to date. She will be eligible to receive the COVID vaccination three months post-transplant. After receiving the second dose, antibody levels will be checked to determine if she mounted an appropriate antibody response. CONCLUSION: We have demonstrated successful heart transplantation without reactivation of COVID-19 with immunosuppression. Patient and donor selection will remain crucial to determine optimal management strategies of recipients who have recovered from COVID-19. Given the lack of data on the management of transplant patients within the COVID era, particularly in the peri-operative setting, findings from individual experiences and case reports will be useful until more guidance is established.