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.)

A Case of Post-Vaccine Myocarditis Mimicking Long Covid

Myocarditis is a rare complication following mRNA-based COVID vaccinations. While the risk appears to be greatest in adolescent males, increased rates of myocarditis following COVID vaccination have been documented in both sexes and across multiple age groups.In this case, a 59- year-old woman with history of mild COVID infection developed unexplained fatigue, diminished exercise capacity, and intermittent chest discomfort several days after receiving her first dose of the Pfizer-BioNTech COVID-19 vaccine. She was seen in the emergency department at the onset of symptoms and found to have a dynamic troponin elevation peaking at 177 ng/L. A comprehensive workup including regadenoson stress testing, CT scan of the chest with contrast, and ambulatory cardiac monitoring failed to demonstrate an etiology. She subsequently received a second dose of the COVID-19 vaccine which resulted in worsening cardiopulmonary symptoms that persisted over the next several months. Her symptoms were initially attributed to long COVID, and she was provided supportive care and an SSRI for anxiety. After reevaluation in the Cardiology clinic, the patient underwent cardiac MRI revealing edema in the basal lateral wall and late gadolinium enhancement in a subepicardial distribution, suggestive of myocardial inflammation. She was treated with prednisone 50 mg daily and colchicine 0.6 mg twice daily resulting in resolution of chest pain. A repeat MRI performed two weeks later showed complete resolution of myocardial edema with residual subepicardial LGE in the basal lateral wall consistent with prior myocarditis.This case demonstrates the pitfalls of relying on a diagnosis of 'long COVID' to explain concerning cardiac symptoms of uncertain etiology and highlights post-vaccine myocarditis as an important differential in the COVID-19 era. At this time, it is unclear how many patients experience persistent cardiopulmonary symptoms following COVID vaccination and whether a subset of these patients have undiagnosed myocarditis. It is important for clinicians to be alert to the possibility of post vaccine myocarditis in patients presenting with persistent symptoms following vaccination, regardless of demographic profile.

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.

Comparison of cannulation approaches for venovenous extracorporeal membrane oxygenation during covid-19

Purpose: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is performed through various cannulation approaches but an optimal strategy remains uncertain. Methods: A retrospective, multi-center study was conducted. Adult patients (≥18 years old) placed on VV-ECMO for severe respiratory failure due to COVID-19 between March 1, 2020, to April 30, 2021, across the United States were included. Patients were divided into the following 3 groups based on initial cannulation: 1) femoral vein-femoral vein or femoral vein-internal jugular vein (Dual-Site, DS), 2) single, dual-lumen cannula in internal jugular vein with tip positioned in the pulmonary artery (PA) and 3) single, dual-lumen cannula in internal jugular vein with tip positioned in the inferior vena cava (IVC). The primary outcome was in-hospital mortality after VV-ECMO placement assessed by a time-toevent analysis. Results: Overall, 435 patients from 17 centers comprised the study cohort. DS cannulation was performed in 247 (age: 47±11, 30% female) cases, 99 (age 50±12, 26% female) received PA, and 89 patients got IVC (age 45±12, 33% female). At 90 days, in-hospital mortality across cannulation groups was 60% (DS), 41% (PA) and 61% (IVC), p=0.06 (Figure 1). After adjustment for clinical covariates, the likelihood of in-hospital mortality in comparison to DS, was lower with PA (aHR: 0.60, 95%CI 0.40-0.91, p=0.02) and similar with IVC (aHR: 0.99, 95%CI 0.68-1.43, p=0.95). Conclusion: Catheter directed flow into the PA with a single dual-lumen cannula is associated with reduced mortality during VV ECMO for COVID-19.

Direct versus indirect thrombin inhibition during extracorporeal membrane oxygenation support for covid-19

Purpose: Anticoagulation during extracorporeal membrane oxygenation (ECMO) for COVID-19 can be carried out by direct or indirect thrombin inhibition. The former agent obviates monitoring of antithrombin III but differences in outcomes with either approach are uncertain. Methods: A retrospective, multi-center study was conducted. Adult patients (≥18 years old) placed on ECMO for severe respiratory or circulatory failure due to COVID-19 between March 1, 2020, to April 30, 2021, in the United States were included. Patient were divided in 2 groups based on the utilized anticoagulation agent during ECMO support: 1) direct thrombin inhibitor (DTi, e.g. bivalirudin and argatroban) and 2) indirect thrombin inhibitor (IDTi, e.g. unfractionated heparin). The primary outcome was in-hospital mortality after ECMO placement assessed by a time-to-event analysis. Results: Overall, 455 patients from 17 centers were placed on ECMO, of whom 44 were excluded due to no reported anticoagulation agent. DTi was used in 160 (age: 47±11, 28% female) cases and 251 patients received IDTi (age 47±12, 29% female). At 90 days, in-hospital mortality was 50% (DTi) and 61% (IDTi), p=0.08, (Figure). After adjustment for clinical covariates, the likelihood of in-hospital mortality was similar with DTi (aHR: 0.79, 95%CI 0.57-1.10, p=0.16) compared to IDTi. Noted prevalence of deep vein thrombosis (DTi 14%, IDHi 12%), ischemic stroke (DTi 2%, IDHi 3%), intracranial hemorrhage (DTi 11%, IDHi 10%) and bleeding requiring transfusion (DTi 71%, IDHi 83%) was comparable between groups. Conclusion: Anticoagulants that directly or indirectly inhibit thrombin are associated with similar outcomes during ECMO for COVID-19.

Decongest the Clinic—a Compulsory Experiment with Virtual Heart Failure Care In the Bronx

Introduction: At the epicenter of the COVID-19 pandemic, there was an urgent need to limit the exposure of patients (pts) to SARS-CoV-2. This required shuttering high risk areas which included outpatient offices;however, the ongoing acuity of heart failure (HF) pts concurrently mandated close follow up. To overcome this predicament, at our institution pts were asked to stay at home and engage in virtual HF visits (VHFVs) via telephone or video, in lieu of in-office visits (IOVs). The purpose of this abstract is to summarize and assess the feasibility of our initial 30 day experience with VHFVs. Methods: The Montefiore- Einstein Heart Failure service cares for over 4,000 pts who predominantly reside within the Bronx borough, and represent a vulnerable, urban, low socioeconomic population. Our team includes 12 providers consisting of both NPs and MDs. On 3/17/20 all non-urgent IOVs were stopped and as a work around a virtual platform was created within our electronic medical record system (EPIC) to facilitate VHFVs. As of April 1st, all IOVs were converted to VHFVs. We retrospectively reviewed the HF clinical volume for the month of April 2020 and as a reference compared it to the same time period in 2019. In addition, we followed high risk pts (defined as those requiring multiple visits during the month for acute decompensated HF [ADHF] or renal failure) for clinical outcomes including hospital admission. Results: Over the 30 day period from April 1-30th 2020, 510 HF pts had a total of 605 VHFVs and 17 IOVs. Seventy-five pts required ≥2 visits during this time period of which 26 pts (5%) were categorized as high risk as defined above. Providers reported that 7 (27%) of these pts would have been electively hospitalized under normal circumstances. In the 30 days following initial VHFV, 3 (12%) were urgently hospitalized, 2 of whom would have been electively admitted by provider as above, and none died. Interestingly, clinical volume and outcomes of high risk individuals was comparable in April 2019 (Table 1). Three of 12 (25%) patients with ADHF or renal failure were urgently hospitalized in the 30 day follow up period. At the time of this presentation we intend to report 90 day outcomes on all pts. Conclusion: In this preliminary analysis of an experiment that was brought on by the COVID-19 epidemic, VHFVs were not associated with substantially worse clinical outcomes over the short term. Table 1: Comparison of Visit Volumes - April 2019 vs 2020