ABSTRACT
The optimal COVID-19 vaccination strategy in solid organ transplant recipients (SOTRs) remains unclear. We conducted a living systematic review and network meta-analysis (NMA) to explore COVID-19 vaccination strategies in SOTRs. We conducted a search of databases from inception to July 2022 for all studies comparing any COVID-19 vaccination strategy in SOTRs. We performed a NMA to evaluate the impact of various vaccination strategies on COVID-19 infection, and COVID-related mortality. We used the GRADE approach for NMA to judge our certainty in the evidence. Of 2,534 publications identified, 27 proved eligible (4 RCTs, 23 observational). Identified RCTs were only subject to narrative summarization due to heterogeneity in their research questions (Figure A). Nine observational studies (76,703 SOTRs, 6.3% heart transplant, 5.2% lung transplant) reported adjusted hazard ratios (HRs) for COVID-19 infection and/or COVID-related mortality. The NMA for the impact of various doses of vaccines on COVID-19 infection suggested a dose-response relationship (Figure B). Compared to no vaccination, three (HR 0.16, 95%CI 0.11-0.22, moderate certainty) or two (HR 0.45, 95%CI 0.35-0.58, moderate certainty) doses of any COVID-19 vaccine showed a strong effect on reducing COVID-19 infection. One dose showed a moderate effect (HR 0.73, 95%CI 0.49-1.07, low certainty) on reducing COVID-19 infection. Two doses of any vaccine showed a moderate effect on lowering risk of mortality in COVID-19 infected SOTRs (HR 0.74, 95%CI 0.63-0.89, low certainty). We did not identify sufficient data to explore effect modification by organ group or immunosuppressant use. Current evidence suggests that increasing the number of COVID-19 vaccination doses may provide increasing protection against COVID-19 infection in SOTRs (moderate to low certainty). Further studies are needed to better understand the impact of COVID-19 vaccination on all patient-important outcomes. [ABSTRACT FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)
ABSTRACT
Purpose: Gene expression profiling (GEP) and donor-derived cell-free DNA (dd-cfDNA) provide effective non-invasive rejection surveillance for heart transplant (HT) recipients with a trend toward improved quality of life. During the COVID-19 pandemic, rejection monitoring and titration of mediations in HT patients was difficult due to limited health-care resources for endomyocardial biopsy (EMBx). This is the first Canadian study to assess non-invasive rejection surveillance in improving patient satisfaction and reducing anxiety during HT rejection screening. Methods: Adult HT recipients, at least 6 months post-transplant, were enrolled to have surveillance EMBx replaced by non-invasive rejection testing with GEP and dd-cfDNA. Patients with multiorgan transplant, dialysis, or high rejection risk (recent acute cellular rejection ≥ grade 2R, new graft dysfunction, or heart failure) were excluded. All patients completed the Medical Outcomes Study 12-item Short Form Health Survey (SF-12) and a patient satisfaction survey. Thematic analysis was performed for open-ended responses. Results: Out of 90 patients screened, 31 had their routine EMBx replaced by non-invasive rejection testing. Based on test results, 89% of EMBx were safely eliminated. On the SF-12, participants had a median physical health score of 43 (40-53) and mental health score of 53 (46-58) out of 100. Patients’ self-reported satisfaction was 90%. Median self-reported anxiety score prior to EMBx was 50 (10-71) versus 2.5 (0-7.5) out of 100 prior to GEP/dd-cfDNA. Four codes (“emotions” (pain, anxiety, fear), “time”, “biopsy”, “accuracy”) were used to uncover two themes of “Superiority to Biopsy” and “Mental or Physical Stress”. Patients described feeling much more satisfied and less emotionally distressed with the non-invasive screening compared to EMBx. HT patients reported less fear and anxiety, reduced pain, and enjoyed the simplicity of non-invasive testing. Conclusion: Non-invasive rejection surveillance screening can positively impact patients’ mental health. In this study, non-invasive rejection surveillance eliminated the recovery time and risk of an invasive procedure for HT recipients while reducing anxiety, improving patient satisfaction, and providing an alternative way to screen patients during a period of limited resources due to a global pandemic.
ABSTRACT
Introduction: Myocarditis is an inflammatory disease of cardiac muscle caused by a variety of infectious and non-infectious conditions. Viral infection is the most frequent cause of myocarditis;however, herpes simplex virus 1 (HSV-1) infection causing myocarditis has been rarely described. We present a case of a young woman with HSV-1 viremia and fulminant myocarditis presenting with cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO), complicated by hyperhemolysis. Case Report: A 35 year-old immunocompetent woman with moderate alcohol consumption presented to hospital with a 4-day history of fever and flu-like symptoms. She was fully vaccinated for COVID-19 two months prior to symptom onset. Her COVID-19 testing was negative and she was discharged home. She returned to hospital 4 days later in cardiogenic shock. Transthoracic echocardiogram demonstrated LVEF of 30% with a small pericardial effusion. Coronary angiogram revealed normal coronaries. She was placed on peripheral VA-ECMO for worsening cardiogenic shock. Due to inadequate LV unloading, she underwent atrial septostomy. Five days after VA-ECMO cannulation, HSV-1 was detected in the blood and she was started on intravenous acyclovir. Her ECMO course was complicated by acute kidney injury requiring dialysis, and hyperhemolysis with a peak LDH of 12,000 U/L. The mechanism of hemolysis was attributed to an intravascular process (plasma free hemoglobin 7487 mg/L, normal < 150 mg/L) likely from a combination cold agglutinins and the mechanical circuit. Interestingly the membrane pressure gradient was within normal. The patient received treatment with plasmapheresis (Table 1), and was eventually decannulated after 12 days following hemodynamic improvement. This case report highlights a rare viral cause of fulminant myocarditis and emphasizes the need for collaboration among various specialists in the management of complex cases.
ABSTRACT
Purpose The current COVID-19 pandemic has had an unprecedented impact on healthcare systems across the world. It has stretched to the limit acute care systems, indirectly it has shaped new and innovative ways to deliver care for those with chronic conditions. Herein we describe initial outcomes of the rapid virtualization of the Heart Function Clinic at a major quaternary Hospital in Toronto, Ontario. Methods Consecutive patients attending the heart function clinic at the Toronto General Hospital between March 9, 2020 and June 30, 2020 were included. Visits were classified as “in-person” if patients were physically present for the clinical interaction and “virtual” if the clinical interaction occurred while the patient was away using currently available modes of communication: telephone or web-enabled (Ontario Telemedicine Network -OTN, or other available web-based applications). The purpose of the individual visit was categorized as: “surveillance”, “titration”, “new assessment” or “Clinical trial”. Results A total of 292 patients had a total of 521 clinical encounters during the lockdown period. Of these, 168 (32.2%) were “in-person”, while 353 (67.8%) were “virtual”. 101 (19.3%) were primarily for the purposes of titration. These virtual assessments led to 14(2.7%) in-person assessments. 258 (49.5%) of patients had an LVEF < 40%, among these patients 220 (85.3%) were on an ACEi, ARB or ARNi, 242 (93.8%) on a Betablocker, 191 (74%) on an MRA, 46 (17.8%) on SGLT2inhibitor. Conclusion Rapid virtualization of a large academic multi-disciplinary clinic is possible. This allows for ongoing delivery of safe care to patients with chronic conditions and can be used as a model for other clinics facing the pandemic. Lessons learned will be used to transition to a hybrid model of in-person and virtual even after the pandemic has come to an end.