Systemic Sclerosis as a Challenge for Heart Transplantation: A Case Report.

OBJECTIVE: To assess the principles of qualification and the range of organ transplantation in a patient with diagnosis of system sclerosis with pulmonary manifestation and severe myocardial insufficiency. METHODS: We present the case of a 43-year-old patient with confirmed systemic sclerosis with pulmonary manifestations and biventricular heart insufficiency after disease exacerbation and sudden cardiac arrest in the pulseless electrical activity (PEA) mechanism with effective resuscitation, with increasing shortness of breath and the need for inotropes and levosimendan infusion without a significant improvement in his general status. Owing to the diagnosis of a systemic disease with no option for pharmacologic or any other treatment for heart failure, he was reevaluated and put on an urgent waiting list for isolated heart transplantation. After 7 days, heart transplantation was performed. Given the risk of disease progression and the possibility of future lung transplantation, the pleural cavities were untouched. The standard immunosuppression protocol was followed with the use of rabbit antithymocyte globulin. RESULTS: The patient was extubated at 24 hours after heart transplantation. The results of endomyocardial biopsies performed during the hospital stay and at a 6-month follow-up were negative. The patient was discharged to home after 22 days of an uneventful hospital stay. CONCLUSIONS: Scleroderma as an autoimmunologic disease remains a challenge for the transplantation team as a possible progressive multiorgan insufficiency requiring qualification for organ transplantation. The course of the disease varies depending on the form of systemic sclerosis. Careful assessment, qualification, and determination of appropriate preprocedure and postprocedure immunosuppressive treatment are essential to an uncomplicated course of treatment.

Utility of 64-Slice Coronary Computed Tomography Angiography in Heart Transplant Recipients.

BACKGROUND: Graft vasculopathy is a leading cause of death after heart transplantation (HTx). Diagnosing cardiac allograft vasculopathy (CAV) within this patient group poses significant challenges. This study aimed to evaluate the safety and efficacy of coronary computed tomographic angiography (CCTA) in patients after HTx. METHODS: We enrolled 107 consecutive HTx recipients (26 women, mean age 50 ± 17 years); all were ≥3 years post-HTx with minimal or no evidence of CAV in a prior coronary angiography performed a minimum of 2 years before the current examination. The inclusion criteria comprised an estimated glomerular filtration rate (eGFR) of ≥30, absence of new heart failure symptoms, and no contraindications to iodine contrast or CT scans. All patients underwent a 64-slice CCTA. In cases of minimal or no changes, noninvasive follow-up examinations were conducted. Significant changes in CT prompted additional coronary angiography. RESULTS: Of the enrolled participants, 9 exhibited minimal changes; 98 displayed no changes in coronary angiography. The median time since transplant was 7 years, with IQR of 4 to 11.25 years. Significant changes were excluded in 98 patients. Among the 9 patients with suspected significant CAV, significant changes were confirmed in 8 patients, resulting in percutaneous transluminal coronary angioplasty (PTCA) performed in 6. One patient from this group died shortly after PTCA. No cardiovascular incidents were observed within the remaining group. The median follow-up period was 539 (IQR = 289-654 days). The mean left ventricular ejection fraction at follow-up was 58% ± 5% compared with 58% ± 4% at baseline. At follow-up, the mean eGFR was 64 ± 18 mL/kg/1.73 m2 compared with the baseline value of 67.2 mL/kg/1.73 m2. CONCLUSIONS: CCTA appears to offer a secure and efficient means of assessment in HTx recipients.

Assessment of Selected Parameters of Heart Donors and Recipients and Their Impact on the Transplantation Result.

OBJECTIVE: To evaluate the impact of heart donors and recipients parameters on the outcomes after orthotopic heart transplantation (OHT). METHODOLOGY: Two hundred fifteen patients who underwent OHT from 2020 to 2023 were analyzed. RESULTS: Average donors age 36.3 (±13.1) years, 74 women (34.42%), BMI 25.3 (±4.99), Na+ concentration 153.7 (±11.8) mmol/L. Mean intraventricular septum thickness 10.0 (±2.2) mm, left ventricular end-diastolic diameter 44.3 (±6) mm, ejection fraction 60.3 (±7.92) %. Median procalcitonin was 0.6 ng/mL. Levonor was used in 75.8%, Empressin in 4.2%, Dopamine in 5.1%, Dobutamine in 3.7%, and Adrenaline in 3.7% of donors. The most common cause of death: intracranial injury (34.42%). Cardiopulmonary resuscitation occurred in 34%, alcoholism in 20.9%, nicotinism in 16.3%, and drug addiction in 7.4% of donors. Mean aortic cross-clamping time was 200.3 (±48.8) minutes. Intra-aortic balloon pump (IABP) after OHT required 6.1%, extra corporeal membrane oxygenation (ECMO) 6.1%, and renal dialysis 36% of recipients. The 1-year mortality rate was 19.1%. Death after OHT correlated with: longer aortic cross-clamping time (207.6 vs 198.59 minutes, P = .292), longer extracorporeal circulation time (196.3 vs 186.47 minutes, P = .335), lower Empressin dose (median 0.01 vs 0.02 j.m/min, P = .03) in donors, longer postoperative mechanical ventilation (mean 101.46 vs 23.09 hours, P = .001), more frequent dialysis, IABP or ECMO (P = .001) and older age of the recipient (51.2 vs 44.8 years, P = .014). Previous cardiac surgery or any surgical intervention after transplantation significantly influenced mortality. The remaining donor factors had no impact on the OHT result. CONCLUSIONS: Identification of risk factors in the donor and recipient may improve treatment outcomes after OHT.

The Results of Minimally Invasive Implantation of the HeartMate 3 LVAD Left Ventricular Assist Device.

OBJECTIVE: To evaluate the safety, feasibility and effectiveness of minimally invasive HeartMate 3 LVAD implantation. METHODOLOGY: Forty-seven patients who underwent the HeartMate 3 LVAD implantation by sternotomy and 26 ones who had implantation via minimally invasive method were analyzed. The observation lasted from November 2016 to May 2020. RESULTS: ECMO as a bridge to LVAD, was more usual in the sternotomy group (11% vs 0%, P = .03). In the minimally invasive group, a history of previous cardiac surgery was more common (54% vs 12%, P < .001), this was the main indication for a minimally invasive approach in our institution. Patients undergoing a minimally invasive implantation had a significantly longer duration of surgery (Med. = 367.5 min vs Med. = 265.0 minutes, P < .001), and significantly higher intraoperative use of fresh frozen plasma (FFP) and platelet concentrates (PCs). There was no significant difference in the number of postoperative bleedings requiring surgical intervention. Postoperative wound infections were observed significantly more often in the sternotomy group (6% vs 0.0%, P < .001). There was no significant difference in survival between groups in the first 180 days after surgery. A slightly lower percentage of patients reached 2-year postsurgery survival in the group undergoing sternotomy, but this finding was not statistically significant. The mean survival time among sternotomy patients was 430.0 days (+/- 291.77 days) vs 633.15 days (+/- 426.84) in minimally invasive group. CONCLUSIONS: Minimally invasive implantation of the HeartMate 3 LVAD may be an alternative method of LVAD implantation in a selected group of patients.

Pediatric Heart Transplantation in the Context of Severe Pulmonary Hypertension Secondary to Restrictive Cardiomyopathy-Case Report.

The aim of this study is to analyze the feasibility of performing an isolated heart transplant in patients with severe pulmonary hypertension as a result of restrictive cardiomyopathy. The results present the clinical course from the diagnosis of restrictive cardiomyopathy at the age of 2 until the heart transplant at 8 years old. Initially, the patient was considered for multiorgan transplantation, heart and lungs, due to extremely high pulmonary resistance. However, due to the prolonged waiting period for a donor and the worsening condition of the child, a decision was made to perforate the atrial septum with the implantation of an atrial flow regulator system. After conducting control hemodynamic measurements, the qualification was changed to an isolated heart transplant, accepting the high operative risk associated with the still elevated pulmonary resistance index of 4.9 Wood units. This study describes the medical problems that occurred during postoperative treatment. The patient underwent an orthotopic heart transplant in her eighth year of life. Postsurgery, complications were observed, including generalized seizures and heart transplant rejection reaction. Immunosuppressive therapies were applied, and efforts were made to combat anemia and electrolyte disorders. While the cardiovascular system and heart parameters improved, there were some difficulties in controlling heart rhythm and stabilizing electrolyte levels.

Thyroid Dysfunction in Advanced Heart Failure Patients and Its Correlation with Amiodarone Therapy: A Two-Year Study.

(1) Background: Advanced heart failure often accompanies ventricular arrhythmias, necessitating antiarrhythmic therapies. Amiodarone, commonly used for this purpose, may induce thyroid dysfunction due to its high iodine content. However, the prevalence and correlation of thyroid dysfunction with amiodarone in end-stage heart failure patients remain unclear. Aim: This study aimed to evaluate the prevalence and types of thyroid dysfunction and their association with amiodarone among 200 patients diagnosed with advanced heart failure eligible for transplantation. (2) Methods: Consecutively enrolled patients received treatment following the European Society of Cardiology guidelines and were followed-up for two years. Ventricular arrhythmias affected 58.5% of the cohort, with 24.5% receiving amiodarone therapy. (3) Results: Thyroid metabolism dysfunction was evident in 61 patients, notably overrepresented in women (p = 0.0028). Hyperthyroidism (34 patients) and hypothyroidism (27 patients) were observed, with a significant amiodarone-related correlation. Despite this, thyroid dysfunction was not associated with increased mortality among the studied group. (4) Conclusions: Thyroid dysfunction is prevalent in advanced heart failure patients, with a notable proportion linked to amiodarone. However, its presence does not correspond to higher mortality rates. Understanding these associations is crucial for effective management in this patient population. Further exploration is warranted to refine approaches to thyroid dysfunction in refractory heart failure.

Does the induction immunotherapy (basiliximab) influence the early acute cellular rejection index after orthotopic heart transplantation?- Preliminary assessment report.

The study aimed to determine the influence of induction therapy on the acute cellular rejection (ACR) index in adult heart transplant recipients during the one-year observation. The study population consisted of 256 consecutive adult patients (pts), aged 51.5 (±11.9) years, 199 (77%) men treated with orthotopic heart transplantation (OHT) in the period between 2015 and 2020 in a single high-volume heart transplant center. The endomyocardial biopsies (EMBs) were performed according to the protocol consisting of 7 protocolary EMBs for up to 3 months and 10 EMBs for up to one year after OHT. The rejection index (ACRI) was calculated as the number of scheduled EMBs with the ACR ≥ 2 divided by the total number of protocolary EMBs. The study population was divided into two groups according to the application of basiliximab. The total number of pts. who received basiliximab was 10 (3.9%). The main indications for the usage of the induction therapy were heart retransplantation, mechanical circulatory support (MCS), severe renal insufficiency (eGFR <30 mL/min/1.73 m2), and a panel of reactive antibody (PRA) > 10%. In the group with induction, the mean age was 49 (±14) years; 3 (30%) patients had the MCS prior to OHT, and 3 (30%) patients had heart retransplantation. Four (40%) patients had diabetes mellitus, and 4 (40%) patients had severe renal insufficiency. As maintenance therapy during the observation period, tacrolimus was given to 10 (100%) patients, everolimus to 2 (20%) patients, and MPA to 9 (90%) patients. In the group with no induction, the mean age was 51.8 (±12) years, MCS was used in 56 (23%) patients, 2 (0.8%) patients were retransplanted; 10 (4%) patients had eGFR <30 mL/min/1.73 m2 and 58 (24%) patients had diabetes. Tacrolimus was administered to 243 (99%) patients, cyclosporine to 3 (1%), everolimus to 40 (16%), and mycophenolate to 245 (99.6%) heart recipients. The median one-year ACRI was 0.0, IQR:0.0-0.08 in the group with induction vs. 0.077, IQR: 0.0-0.154 with no induction; p = 0.11. ACRI up to three months was significantly higher in the entire cohort in comparison to up to one year (P < 0.01). The multivariate analysis showed that only everolimus implementation and younger age at the time of transplant influenced patients' mortality rate (P < 0.01). Significant graft rejections (≥ 2R ISHLT) are most common in the first three months after OHT. Patients who are initially at high risk of significant cellular rejection may benefit from induction therapy.

Gut Microbiome in Patients after Heart Transplantation-Current State of Knowledge.

The human gut microbiota include over 10 trillion microorganisms, such as bacteria, fungi, viruses, archaea, and protozoa. Many reports indicate the strong correlation between dysbiosis and the severity of cardiovascular diseases. Microbiota seem to interact with the host's alloimmunity and may have an immunomodulatory role in graft rejection processes. In our study, we present the current state of the knowledge of microbiota in heart transplant recipients. We present up-to-date microbiota diagnostic methods, interactions between microbiota and immunosuppressive drugs, the immunomodulatory effects of dysbiosis, and the available strategies (experimental and clinical strategies) to modulate host microbiota.

Torque Teno Virus (TTV)-A Potential Marker of Immunocompetence in Solid Organ Recipients.

Torque Teno Virus (TTV), first discovered in 1997, is a non-pathogenic, highly prevalent virus with a notable presence in the human virome. TTV has garnered attention as a potential indicator of immunocompetence in recipients of solid organ transplants. In this review, we discuss the role of TTV as a potential marker for immunosuppression optimization, prediction of graft rejection, and as an indicator of opportunistic infections. We discuss TTV's behavior over the course of time after transplantation, TTV's implications in different immunosuppressive regimens, and potential utility in vaccinations. The review synthetizes findings from various studies depicting its potential clinical utility for future personalized patient care.

Condition of the Oral Cavity in Patients After Heart Transplantation: A Preliminary Report.

BACKGROUND The constant impairment of the immune system caused by lifelong use of immunosuppressive drugs in patients after heart transplantation has a significant impact on oral cavity health. The aim of this study was to analyze the health of the oral cavity in patients after heart transplantation, with particular regard to occurring pathogens. MATERIAL AND METHODS The study included 25 patients after heart transplantation. The research scheme was divided into 2 parts. The first part consisted of a survey on general health and oral hygiene habits. The second part of the examination consisted of an analysis of the health of the oral cavity: the mucosa, periodontium, and hard dental tissues. Particular attention was paid to PET (test for the presence of pathogens causing periodontitis/periimplantitis) and CAT (diagnostic test for the presence of Candida in the oral cavity), which are real-time PCR tests used to detect pathogens causing periodontitis and microorganisms present in oral candidiasis. RESULTS The conducted research and in-depth analysis of the results showed that the oral health condition in patients after heart transplantation is not satisfactory, regardless of the time that has elapsed since the surgery, sex, age, hygiene habits, or the type of immunosuppression used. The oral cavity of patients after heart transplantation is colonized with Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Treponema denticola, and Candida albicans. CONCLUSIONS The cooperation of the dentist with the attending physician at each stage of the treatment should play an unquestionable role.

Novel Hybrid Treatment for Pulmonary Arterial Hypertension with or without Eisenmenger Syndrome: Double Lung Transplantation with Simultaneous Endovascular or Classic Surgical Closure of the Patent Ductus Arteriosus (PDA).

Patients with pulmonary arterial hypertension (PAH) become candidates for lung or lung and heart transplantation when the maximum specific therapy is no longer effective. The most difficult challenge is choosing one of the above options in the event of symptoms of right ventricular failure. Here, we present two female patients with PAH: (1) a 21-year-old patient with Eisenmenger syndrome, caused by a congenital defect-patent ductus arteriosus (PDA); and (2) a 39-year-old patient with idiopathic PAH and coexistent PDA. Their common denominator is PDA and the hybrid surgery performed: double lung transplantation with simultaneous PDA closure. The operation was performed after pharmacological bridging (conditioning) to transplantation that lasted for 33 and 70 days, respectively. In both cases, PDA closure effectiveness was 100%. Both patients survived the operation (100%); however, patient no. 1 died on the 2nd postoperative day due to multi-organ failure; while patient no. 2 was discharged home in full health. The authors did not find a similar description of the operation in the available literature and PubMed database. Hence, we propose this new treatment method for its effectiveness and applicability proven in our practice.

Treatment of Pediatric Patients With COVID Infection After Heart Transplantation.

The COVID-19 pandemic that has been ongoing since the beginning of 2020 has forced health care into a difficult struggle for wellness and the lives of patients. International data and our observations show that the course of the disease in these patients is different than in the general population. Symptoms depend on the immunosuppression and severity of viremia. The period of viral replication is much longer. Our observations include 4 pediatric patients post heart transplant who became infected with the coronavirus. One patient was infected in the hospital during perioperative period. Two others required hospitalization because of the severity of symptoms, and 1 was treated on an outpatient basis. The applied treatment included the reduction of immunosuppression, low-molecular-weight heparin, amantadine or remdesivir, steroids, and supplementation with zinc and vitamins C and D. Based on the antigenic tests performed, we determined the period of active replication to be 3 to 8 weeks from the onset of the first symptoms.

Serologic Status According Severe Acute Respiratory Syndrome Coronavirus 2 in Patients After Orthotopic Heart Transplantation.

BACKGROUND: The SARS-CoV-2 pandemic is ongoing. In this context, patients after organ transplantation are especially endangered because of their increased susceptibility to infections. Real effectiveness of vaccinations against SARS-CoV-2 and exposition to the virus in populations after organ transplantation is still being assessed. METHODS: We investigated 371 adult patients (82.7% men, 17.3% women), aged 54 ± 14 years, with a median time from transplantation of 1296 days (interquartile range, 473-400 days) after orthotopic heart transplantation consecutively admitted to the transplant center between February and September 2021. SARS-CoV-2 spike protein antibodies were assessed quantitatively by Elecsys Anti-SARS-CoV-2 S. Data according to past COVID-19 infection and vaccination were compared with the test results. Among the whole group, 59 patients were unvaccinated and had no past COVID-19 infection, 200 patients had a full course of vaccination (2 doses) with an mRNA vaccine, 1 patient had received a viral vector vaccine, 11 patients had had a single dose of an mRNA vaccine, and 99 patients had previously had a COVID-19 infection. Median time from vaccination to antibody assessment was 54 days (interquartile range, 30-76 days). AIM: The aim of this study was to determine exposure to the virus among patients after heart transplantation before vaccination and humoral response to the vaccination and assess the role of antispike antibodies in the prevention of infection. RESULTS: After vaccination, 22.3% had no antibodies (45 patients), 47.3% had titers between 0.8 U/mL [0.82 binding antibody units (BAU)/mL] and 250 U/mL (257.25 BAU/mL; 95 patients), and 30.2% had titers above 250 U/mL (257.25 BAU/mL; 61 patients). After a single dose of vaccine, 63% patients had no antibodies. In the group of unvaccinated patients, 3 patients had titers above 250 U/mL (257.25 BAU/mL; 5.1%) and 12 patients had titers up to 250 U/mL (257.25 BAU/mL; 20.3%). In patients after COVID-19 infection, only 2% did not show antispike antibodies, and in 61.4% the titers were above 250 U/mL (257.25 BAU/mL). In the group of patients infected after the full course of vaccination (4 patients after a single dose and 2 after 2 doses), none of the patients developed antibodies after vaccination. Up to the end of September 2021, none of the patients with antibodies against SARS-CoV-2 developed COVID-19. CONCLUSIONS: The presence of spike protein antibodies may be a relevant marker of effective vaccination. In patients after heart transplantation, exposure to SARS-CoV-2 is high.

Patients After Orthotopic Heart Transplantation With COVID-19: Are We Fast Enough With Vaccinations?

BACKGROUND: Patients after orthotopic heart transplantation (HTx) are especially susceptible to infections owing to permanent need for immunosuppression. Vaccinations against COVID-19 have been available since January 2021 and are recommended in organ recipients. AIM: The aim of this study was to analyze COVID-19 susceptibility and mortality in HTx and number of patients with COVID-19 previously vaccinated against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). PATIENTS AND METHODS: We analyzed a whole cohort of 552 patients after HTx who were SARS-CoV-2 positive and remained under surveillance of the transplantation center during March 2020 to September 2021. RESULTS: Among 552 patients after HTx, 10 were COVID-19 survivors prior to transplantation and 103 had SARS CoV-2 infection after transplantation. Mean age of patients with COVID-19 was 55.6 (±14) years, and mean time from transplantation to SARS-CoV-2 infection was 2856 (±2596) days (range, 16-9569 days; interquartile range, 397-4763 days). Among the patients who were COVID-19 positive, 15 were asymptomatic, 10 died, and 51 infections occurred in the era of vaccinations. In the group of patients who were positive for COVID-19 in 2021, 6 received only a single dose of the mRNA vaccine and 3 were vaccinated twice. Among the vaccinated patients with COVID-19, 2 died of severe COVID-19: 1 after a single dose and 1 after 2 standard doses of the vaccine. CONCLUSION: We observed high susceptibility to SARS-CoV-2 infection in the group of patients after HTx. The majority of patients infected in 2021 did not received the vaccine. Vaccination does not fully protect against severe COVID-19 in patients after HTx.

Pregnancies After Orthotopic Heart Transplantation: A Single-Center Experience.

BACKGROUND: Patients who underwent orthotopic heart transplantation have improved survival and quality of live. Some of them are women of childbearing age and have a wish to be pregnant. If the decision to have a child is made, the patient needs a multidisciplinary approach. MATERIAL AND METHODS: We analyzed the whole cohort of patients after orthotopic heart transplantation. From the whole group we extracted women of childbearing age between 16 and 45 years and at least 1 year after transplantation (85 patients). From this group, 8 patients gave birth to children. RESULTS: No cardiocirculatory problems were observed in the mothers during pregnancy and in follow-ups. Strong changes in immunosuppressive drug levels were observed during and directly after the pregnancies. Two children were born prematurely (at 31 and in 34 weeks of gestation). Two children developed cardiomyopathy (the same as in mother). CONCLUSION: The decision of childbearing should be made individually considering each patient's medical history and potential risks connected with the pregnancy. Pregnancy after heart transplantation is relatively safe for the mother. Risk of transmitting cardiomyopathies to the children, especially hypertrophic cardiomyopathy, is high. The patients should be aware of this fact and be carefully counseled preconceptionally.

Patient-Related Preoperative Clinical Factors Influencing 1-Year Survival After Orthotopic Heart Transplantation - A Single Center Polish Experience.

BACKGROUND End-stage heart failure is a growing problem in Poland. Orthotopic heart transplantation remains the best treatment option. Although increasing, the number of heart transplants is disproportionately low compared with patient need. Therefore, it is crucial to identify factors contributing to improvement of heart transplantation outcomes. To find factors providing best survival and optimal recipient selection, we analyzed pretransplant patient-related clinical factors. MATERIAL AND METHODS Between May 2015 and May 2020, we performed 258 cardiac transplants at our institution. We reviewed possible patient-related clinical factors affecting the 1-year survival of our patients and analyzed factors related to survival. Mean age at transplant was 53.5 (±11.8) years; 22.9% of patients were women. Preoperative factors were analyzed using univariable and multivariable analyses. RESULTS In this cohort, 31.8% were diabetic, 43% had ischemic etiology of heart failure, and 15.3% had reversible pulmonary hypertension. Mechanical circulatory support was used in 22%. During 1-year observation, 64 (24.8%) patients died. Univariable analysis showed ischemic etiology (hazard ratio [HR]=2.05, CI=1.227-3.429; P=0.01) and left ventricular assist device were associated with 1-year risk of death (HR=1.953, CI=1.090-3.499; P=0.02). Urgent listing trended toward worsened prognosis (HR=1.509, CI=0.95-2.397; P=0.08). Multivariable analysis showed ischemic etiology (HR=1.81, CI=1.075-3.059; P=0.03), total mechanical circulatory support (HR=1.93, CI=1.080-3.437; P=0.03), decreased eGFR (HR=0.987, CI=0.975-0.998; P=0.03), and protein level (HR=0.97, CI=0.951-0.998; P=0.04) were independently associated with worse 1-year survival after transplantation. CONCLUSIONS Ischemic etiology and mechanical circulatory support were the most important preoperative factors. Malnutrition and renal failure were additional risk factors. Age alone did not influence 1-year survival.

Clinical insights into the role of immunosuppression in solid organ transplant recipients with COVID-19.

INTRODUCTION: The COVID-19 pandemic has disproportionately affected patients who have undergone solid organ transplantation (SOT). OBJECTIVES: We aimed to assess a cohort of transplant recipients who developed COVID­19, with a focus on immunosuppressive regimen, blood tacrolimus levels, clinical course, and patient and graft outcomes. PATIENTS AND METHODS: During the first 12 months of the pandemic, we identified ambulatory SOT recipients, including kidney, liver, and heart transplant recipients, diagnosed with SARS­CoV­2 infection. Baseline and follow­up data on graft function, immunosuppression, and patient and graft outcomes were assessed. RESULTS: Of the 2091 ambulatory patients, we identified 201 transplant recipients (9.6%) with SARS­CoV­2 infection (kidney transplant, n = 112; heart transplant, n = 56; liver transplant, n = 33). Patients after recent kidney (during 2015-2020) or heart (during 2020) transplant were significantly more often diagnosed with COVID ­19 than patients with a longer time since transplant. Additionally, blood trough tacrolimus levels measured during or shortly after COVID­19 in 23 kidney graft recipients were significantly increased by a median of 76.1% (interquartile range, 47.4%-109.4%) relative to predose trough levels. However, liver function parameters were not elevated, necessitating a tacrolimus dose reduction in 73.9% of the patients. CONCLUSIONS: In our study, kidney transplant recipients showed significant disturbances of tacrolimus metabolism, which may account for kidney function worsening during COVID­19. Moreover, infection was more common in patients with recent kidney or heart transplant, which suggests that the level of immunosuppression may affect morbidity related to SARS­CoV­2 infection.

Heart Retransplantation From an Hepatitis B Core Antibody (Anti-HBcore)-Positive Donor: A Case Report.

Heart transplantation is performed in patients with end-stage heart failure. The number of suitable donors for patients on the urgent heart transplantation waiting list is still low, and effort has been made to increase the number of suitable donors, including extended-criteria donors. We present a case report of heart retransplantation because of graft failure from an hepatitis B core antibody (anti-HBcore-positive, HBcAb [+]) and HBs antigen-negative (HBsAg [-]) donor to a seronegative recipient. We show that the procedure, with the use of antiviral prophylaxis, is a safe option for the recipient. Based on anatomopathologic and histopathologic examination of the explanted graft, we also suggest that acute cellular rejection in the transplanted heart may exist despite negative findings in right-sided endomyocardial biopsy.

COVID-19 morbidity in patients after orthotopic heart transplantation - single center clinical observation.

INTRODUCTION: The study is a prospective clinical observation of patients after orthotopic heart transplantation in a large academic medical center in relation to COVID-19 morbidity. The study population was comprised of 552 patients. All patients were consulted and advised by telephone as regards the prophylaxis of SARS-CoV-2 infection. Hospital and outpatient follow-ups were limited to the minimum. Preventive modification of immunosuppression was not recommended in relation to the pandemic. Three patients with multiple comorbidities (a woman aged 60, a man aged 59, and another man aged 83; 2.25 years, 5.5 years, and 7.5 years after heart transplantation, respectively) and one patient with concomitant arterial hypertension (a woman aged 48, 5.5 years after heart transplantation) presented with a symptomatic COVID-19 infection. Three of the patients were on tacrolimus immunosuppression, and both female patients were additionally on therapy with mycophenolate mofetil, which was discontinued following the diagnosis of infection. One male patient received combined therapy of cyclosporine A and mycophenolate mofetil. The 60-year-old woman presented with gastrointestinal manifestations of the COVID-19 infection which were of moderate severity. The recovery was achieved. The 59-year-old man presented with myocardial infarction, exacerbated renal insufficiency that required hemodialysis and cardiorespiratory failure complicated by bacterial sepsis. As a result, the patient died. The 83-year-old male patient reporting fever, myalgia, fatigue, cough and dyspnea was admitted to hospital and deceased due to septic shock two days after admission. The 48-year old woman who presented with mild symptoms of the upper respiratory tract infection recovered after two weeks. Symptomatic treatment was used in all the patients. Another male patient (aged 45 years, 8 years after orthotopic heart transplant with no significant comorbidities) was an asymptomatic carrier of SARS-CoV-2 and remained under hospital care. CONCLUSIONS: Of 552 patients after orthotopic heart transplantation, two SARS-CoV-2-related deaths were reported.