Heart Transplantation (ht) from Active and Recently Active Covid19 Donors

HT centers may avoid donors with Covid19 (Cov19) infection due to uncertain risk of virus transmission and possibility of virus mediated myocardial injury. We investigated Cov19 donor utilization, transplant characteristics and early post HT outcomes in the U.S. Between May 2020-June 2022, n=27,862 donors in UNOS had data available on Cov19 NAT tests and organ disposition. Since donors may get Cov19 testing multiple times prior to organ retrieval, additional data on multiple Cov19 NAT was requested and analyzed. Donors were classified Cov19-donors if NAT+ at any time during terminal hospitalization, and subclassified as Active Cov19(A-Cov19) if NAT+ at organ procurement and 'Recently Active Cov19' (rA-Cov19) if NAT+ initially but NAT negative prior to organ retrieval. HT outcomes using Cov19 and nonCov19 donors were compared by Kaplan Meier (KM) and Cox hazards ratio (HR). Prior to organ retrieval, 27,862 donors had 60,699 Cov19 NAT tests done. Of these, n=1445 were Cov19 donors, n=125 indeterminate and n=26,292 nonCov19. Of Cov19 donors, n=1017 were A-Cov19 and n=428 rA-Cov19. 309 HTs used hearts from Cov19 donors and 239 (n=150 A-Cov19, n=89 rA-Cov19) met study criteria. Compared to nonCov19, Cov19 donors used for adult HT were younger [30(23-37) vs 32(25-40)yrs] and mostly male (80.3% vs 72.1%), p<0.05. Otherwise, HTs from Cov19 and nonCov19 donors were similar in recipient age, race, etiology, UNOS status, BMI, LVAD, ECMO use;and donor LVEF, and DCD status. HTs from Cov19 and nonCov19 donors had similar survival up to 3 months [CoxHR=1.23(0.63-2.39), p=0.54, adjusted for baseline characteristics, Fig1A]. Survival was also statistically similar in A-Cov19 and rA-Cov19 donor HT cohorts [CoxHR=1.47(0.40-5.48), p=0.56, Fig1B]. HTs from Cov19 donors increased from n=5 in May-Dec 2020 to n=207 in Jan-June 2022, p<0.05 for trend. Data on Cov19 treatment was not available. In the largest analysis to date, HTs from selective Cov19 donors had acceptable early outcomes. Longer follow up is needed. [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.)

Weight It Out: Use of Semaglutide for Weight Loss in Patients Undergoing Lung Transplant Evaluation

The obesity epidemic is an on-going barrier to transplant. A body mass index (BMI) ≥35 kg/m2 is considered a risk factor for poor post-transplant outcomes. This presents a challenge to end-stage lung disease patients that often struggle to maintain physical activity secondary to high supplemental oxygen requirements. This can impede weight loss and delay time to listing, especially for patients with a BMI of 30-40 who do not qualify for or who do not wish to undergo bariatric surgery. In this case series, we describe our experience using Semaglutide for weight loss. Utilizing chart review, we identified 3 patients with obesity that utilized semaglutide for weight loss and diabetes management. All were followed by a licensed dietitian and engaged in exercise as tolerated. Our BMI criteria includes BMI ≤32 and ≤30 for evaluation and listing respectively. Exceptions we made at the discretion of the multidisciplinary team. All patients experienced weight loss after starting semaglutide averaging 9kg over an average period of 89 days. Listing for patient 1 was delayed due to COVID-19 infection. Patient 3 lost 6kg while being on semaglutide for 9 days therefore the decision was made to list the patient, as it was anticipated he would continue to lose weight. The medication was well tolerated with no reported side effects. Additional details are shown in table 1. Semaglutide presents an acceptable method for weight loss assistance in patients undergoing lung transplant evaluation. Expedited weight loss can decrease time from referral to listing. Limitations to this weight loss strategy would be medication access in non-diabetic obese patients. Next steps to validate this observed benefit is to launch a formal prospective program that includes this medication as an option in transplant evaluation. [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.)

Lactate Dehydrogenase is Associated with Hemorrhagic Stroke During Extracorporeal Membrane Oxygenation for COVID-19

Background: Hemorrhagic stroke (HS) is a devastating complication during extracorporeal membrane oxygenation (ECMO), but markers for risk stratification are unknown. Lactate dehydrogenase (LDH) is a readily available biomarker of global tissue injury and permeability. We sought to determine whether an elevated LDH at baseline is related to eventual HS during ECMO for COVID-19. Method(s): A multicenter, retrospective study was conducted. Adult patients with COVID-19 requiring ECMO between March 2020 and February 2022 were included. LDH values prior to ECMO were captured. Patients were categorized into high (>750 U/L) or low (<=750 U/L) LDH groups. Result(s): There were 520 patients (47+/-11 years old) that underwent ECMO placement in 17 centers and 384 had an available LDH. In this cohort, 122 (32%) had a high LDH. Forty (10%) patients required venoarterial ECMO, while the remaining 344 (90%) received venovenous support only. Twenty-one out of 122 (17%) patients with a high LDH had a HS in comparison to 21 out of 262 (8%) with a low LDH. At 100 days, the probability of a HS was 40% in the high LDH group and 23% in those with a low LDH, p=0.002. After adjustment for age, sex and antecedent cardiopulmonary resuscitation, high LDH was associated with subsequent HS (aHR: 2.73, 95% CI 1.46-5.12). Findings were similar when restricting to patients supported by venovenous ECMO only. Conclusion(s): Elevated LDH prior to ECMO is associated with a HS during device support. LDH can risk stratify cases for impending cerebral bleeding during ECMO.

COVID-19 Vaccine Triggered Rejection in Lung Transplant Recipients: A Case Series

Purpose Anti-severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) vaccination is recommended by AST, ISHLT, and CDC in all transplant recipients. Lung transplant recipients (LTR) are at a higher risk of developing severe symptoms due to higher immunosuppression (IS) and baseline compromised graft function. Limited antibody response to messenger RNA (mRNA) vaccines has been reported in LTR, with the majority mounting a response after the 2nd dose. In this series, 3 patients developed new and significant respiratory compromise after their 2nd vaccine dose consistent with antibody mediated rejection (AMR). To our knowledge, this is the first published case series of vaccine induced rejection in LTR. Methods Retrospective chart review of our cohort showed 46% fully vaccinated and an additional 2.5% partially vaccinated patients. Three fully vaccinated patients with approved mRNA vaccines (2 Moderna, 1 Pfizer-BioNTech) were identified after developing severe respiratory compromise post 2nd vaccine dose. Evaluation revealed AMR as the underlying etiology. Results All patients were female, ages 50-70 years old, between 6 months and 2 years post-transplant. No previous rejection episodes. All were on standard IS as per institution protocols. Two were hospitalized with hypoxic respiratory failure within 2 weeks of their 2nd vaccine dose. The 3rd was seen at clinic for milder similar symptoms, later progressing and requiring supplemental oxygen (O2) and hospitalization. Imaging showed new lung infiltrates, infectious work up was negative. Biopsies did not show any cellular rejection. All developed new DSAs and received treatment for AMR with plasmapheresis, IVIg, and Rituximab. Two recovered their lung function and are off supplemental O2, the 3rd did not and is re-listed for transplant. Conclusion While LTR have a diminished response to SARS-CoV-2 vaccines making them more vulnerable to the disease, their immune system's response may not always be clear. We report three cases of patients developing severe AMR from new DSAs that appear to be triggered by the COVID-19 vaccine. This vaccine responses should be collected in a database where each case can be investigated to help better understand the mechanism behind them and hopefully identifying LTR at risk. This can then be used to modify vaccination strategies and aid in preventing adverse outcomes in this vulnerable group of patients.