ABSTRACT
Introduction Heart tansplant (HT) recipients constitute a population at risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Efficay and safety of SARS-CoV-2 vaccine in this population is still yet to be established. It has been described, immune thrombotic thrombocytopenia, myocarditis and Guillain-Barre syndrome in individuals who received the ChAdOx1 SARS-CoV-2 vaccine. There are very few cases of acute rejection after SARS-CoV-2 vaccination post HT patients. We will describe a several outcome of heart function vaccine-induced. Case Report A 46-year-old heart transplanted male since 2015, started with persistent cough 15 days after a dose of adenoviral vector-based vaccine against SARS-CoV-2. As he had increased troponin and new left ventricular dysfunction, he underwent an endomyocardial biopsy, collected an panel reactive antibodies (PRA) and started pulse dose metylprednisolone. He developed an ischemic electrocardiographic alteration with a ST elevation and the coronary angiography found a thrombosis in the anterior descending coronary artery with no success with percutaneous treatment. Endomyocardial biopsy found no acute rejection, and PRA showed de novo donor specific antibodies (DSA). Despite treatment for antibodie-mediated rejection with plasmapheresis, human immunoglobulin and rituximab, he had a cardiogenic shock, refractory to inotropic support and intra-aortic balloon pump, requiring peripheral VA ECMO. Regardless of initial hemodynamic response and partial recovery of biventricular function, patient could not stand weaning from ECMO and inotropes. After rejection therapy, PRA showed no antibodies and patient was included in HT list and had a retransplant after 16 days without complications. Summary To the best of our knowledge, this is the firts report of antibodie-mediated rejection in heart-transplant patient with thrombotic complication after ChAdOx1 SARS-CoV-2 vaccine. Although vaccination remains the main approach of preventing SARS-CoV-2 infeccion, transplant recipients were not included in clinical trials, so its safety remains unknown in this population. More studies are needed in order to increase knowledge about vaccine outcomes in these individuals.
ABSTRACT
Introduction The coronavirus 2019 disease (COVID-19) affected almost 40 million people worldwide and caused more than one million deaths. Some conditions are associated with worse prognosis such as heart failure and left ventricular assist device (LVAD) recipients. Case Report A 31-year-old male patient without comorbidities was admitted due to cardiogenic shock and pneumonia. He required IABP and ECMO. The patient recovered from organ dysfunctions and ECMO was weaned off. He persisted dependent on dobutamine and IABP. Echocardiogram showed severe left ventricular dysfunction and moderate right ventricular dysfunction (RVD), but right heart catheterization revealed no pulmonary hypertension. SARS-CoV-2 RT-PCR was negative and myocardiopathy investigation was inconclusive after endomyocardial biopsy. LVAD implantation was planned as a bridge to transplant. A Heart Mate 3 was successfully implanted. The patient presented fever in the operating room and persisted febrile for 3 days. COVID-19 was suspected and SARS-CoV-2 RT-PCR was positive. He was extubated on 3rd postoperative day (POD) and echocardiogram showed only mild RVD. On 5th POD, he became hypoxemic requiring high flow nasal cannula, and chest X-ray revealed multiple pulmonary bilateral opacities. Antibiotics and corticosteroids were prescribed. Echocardiogram showed severe RVD and hemodynamic instability led to milrinone and dobutamine requirement in maximal doses. On 10th POD endotracheal intubation was required. The patient experienced severe acute respiratory distress syndrome (ARDS) and multiple complications: shock, bacterial pneumonia, hemothorax, pneumothorax due to barotrauma and bloodstream infection. He had no thromboembolic events. After 48 days he was free from mechanical ventilation and from inotropes. Echocardiogram showed moderate RVD and pulmonary artery systolic pressure 35mmHg. After 51 days he was discharged from the intensive care unit and is now in rehabilitation program. Summary Severe cases of COVID-19 are associated with a cytokine storm and a prothrombotic state. LVAD recipients are at particular risk of unfavorable outcomes. Besides the higher risk of thromboembolic events, LVAD recipients are more vulnerable to RVD in the setting of ARDS. This could be particularly critical during the perioperative management of RV failure as presented in this case.
ABSTRACT
Purpose Heart transplant(HT) recipients with SARS-CoV-2 infection may be at high risk of developing critical illness. The aim was to describe the characteristics and clinical outcomes of HT recipients with coronavirus-19 disease(COVID-19). Methods We prospectively included all adult HT recipients who received the diagnosis of COVID-19 in our institution. Inclusion criteria were one or more clinical symptoms of SARS-CoV-2 infection in the previous seven days and positive SARS-CoV-2 RT-PCR in nasopharyngeal samples. The enrollment was carried out from April to June, 2020. Demographic features, clinical characteristics, modes of transmission, laboratory data and other known prognosis markers at admission and through follow up were recorded. Patients were categorized according to the ordinal scale developed by WHO Committee. Outcomes and follow up were recorded until Aug/2020. Results Twenty-one HT recipients were included, most of them were men (57%);with median age of 48 years old and median HT time of 12 mo. The majority needed hospitalization. Immunosuppressive therapy was reduced or withdrawn in the majority of patients, except from steroids. Ten patients were classified as having severe disease according to WHO Committee scale. Lymphopenia was an independent predictor of severe disease and absolute lymphocyte count <416/mm3 had 82% of sensitivity and 90% of specificity to define severe disease. Thirty-day mortality was 14%, similar to previously reported in other solid-organ transplant (SOT) cohorts. However, a longer follow up revealed increased 60-day mortality (33%) due to nosocomial infection. Conclusion In this case series of HT recipients with COVID-19, the 30-day mortality rate was similar to that previously reported in SOT recipient's cohorts, but a longer follow up revealed increased later mortality related to long in-hospital stay. Further, lymphopenia was associated with severe disease and worse prognosis. These findings suggest the need for strict long-term follow up of these patients.