Infections In Heart Transplant Recipients Research Articles

Cytomegalovirus infection in heart transplant recipients: Epidemiology, risk factors, and long-term outcomes from a major transplant center in the United States

BackgroundDespite the use of antiviral prophylaxis, cytomegalovirus (CMV) remains a common opportunistic infection following heart transplantation. This study analyzes the rates, risk factors, and outcomes of CMV among heart transplant recipients. MethodsA retrospective cohort study was conducted of adults who underwent heart transplantation between January 1, 2011, and March 31, 2019. The primary outcome was clinically significant CMV infection (csCMVi), defined as CMV disease or asymptomatic infection requiring preemptive therapy. The secondary outcome was all-cause mortality. Patients received valganciclovir prophylaxis up to 6 months, depending on CMV donor/recipient serostatus. Kaplan-Meier curve and multivariable Cox regression were used for outcome analysis. ResultsAmong 553 heart transplant recipients, 101 (18.3%) experienced csCMVi, including 35 (6.3%) with CMV disease. csCMVi was uncommon during prophylaxis. In multivariable analysis, CMV D+/R- status (HR 12.88, 95% CI 6.76-24.56; p<0.001) and lower absolute lymphocyte counts in seropositive recipients (HR 1.48, 95% CI 1.23-1.79; p<0.001), but not CMV D+/R- patients (HR 1.18, 95% CI 0.94-1.47; p=0.162), were significantly associated with csCMVi. Sixty patients died during follow-up, and csCMVi was associated with increased mortality (HR 2.84, 95% CI 1.62-4.98; p<0.001). ConclusionsIn this large cohort of heart transplant recipients, csCMVi was linked to higher mortality. CMV D+/R- serostatus was associated with an increased risk of csCMVi, with lower absolute lymphocyte counts increasing risk only in CMV seropositive recipients. Strategies for optimizing CMV prevention in serodiscordant heart recipients are warranted.

Developing a Risk Prediction Model for COVID-19 Infection in Heart Transplant Recipients Using Artificial Intelligence

Aim: Describe the utility of an inverse reinforcement learning pathway to develop a novel model to predict and manage the spread of COVID-19. Materials &amp; methods: Convolutional neural network (CNN) with multilayer perceptron (MLP) modeling functions utilized inverse reinforcement learning to predict COVID-19 outcomes based on a comprehensive array of factors. Results: Our model demonstrates a sensitivity of 0.67 in the receiver operating characteristic curve and can correctly identify approximately 67% of the positive cases. Conclusion: We demonstrate the ability to augment clinical decision-making with a novel artificial intelligence (AI) solution that accurately predicted the susceptibility of transplant patients to COVID-19. This enables physicians to administer treatment and take appropriate preventative measures based on patients' risk factors.

The COVID-19 Infection in Heart Transplant Recipients: A Cohort Study

Background: Infectious diseases are major complications after solid organ transplantation. Heart transplant patients have a high mortality rate after Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection. Coronavirus disease 2019 (COVID-19) vaccines have shown efficacy in generating specific immune response. This study aims to describe the COVID-19 infection before and after vaccination in heart transplant recipients.&#x0D; Methods: This was a single-center cohort study including 95 heart transplant recipients with laboratory radiological confirmed COVID-19.&#x0D; Results: COVID-19 infection was present before vaccination in 33 (35.78%) patients. The most frequent COVID-19 clinical presentations before vaccination were cough in 21 (63.63%) and myalgia in 19 (57.57%) patients; 12 (36.36%) were hospitalized; 17 (51.51%) cases had oxygen depletion and required supplemental oxygen; none of them needed invasive ventilation. Of the entire 33 COVID-19 patients, two patients (6.06%) re-experienced the disease about two months after complete vaccination and both of them were recovered. 63 heart transplant patients had not experienced COVID-19 before vaccination, of which 59 patients received vaccination. After two months, 23 vaccinated patients were infected with COVID-19 again, and 2 of the 3 patients who were not vaccinated were also infected. Five patients passed away in the whole study.&#x0D; Conclusion: Heart transplant patients infected with SARS-CoV-2 are at greater risk of severe infection and death compared with immunocompetent individuals. Thus, COVID-19 vaccination for all HT recipients is of paramount importance.

(413) Triple Positive Effect? Impact of Vaccination, Early Remdesivir Treatment and Omicron Expansion on the Evolution of Covid-19 Infection in Heart Transplant Recipients

(413) Triple Positive Effect? Impact of Vaccination, Early Remdesivir Treatment and Omicron Expansion on the Evolution of Covid-19 Infection in Heart Transplant Recipients

The Impact Of Years Since Transplant On The Clinical Course After SARS-CoV-2 Infection In Heart Transplant Recipients

The Impact Of Years Since Transplant On The Clinical Course After SARS-CoV-2 Infection In Heart Transplant Recipients

Severity of SARS-CoV-2 Omicron variant infection in heart transplant recipients

SARS-CoV-2 Omicron variant was first detected in France mid-November 2021 in wastewater treatment plants while cases started to increase at the beginning of December. The maximum incidence occurred in mid-January 2022. The Omicron wave spread rapidly throughout France in general population with lower case-fatality rate compared with previous waves. Little is known about infection with Omicron variant in heart transplant (HT) recipients. In this study, we examined incidence and mortality rate of COVID-19 in the general population and among 1,263 HT recipients during the period from June, 2021 to February, 2022, described characteristics of HT recipients infected with SARS-CoV-2 during Omicron (December 1st, 2021-February 7, 2022) and Delta (June 1st- November 30, 2021) periods, and compared hospital course of HT recipients with Omicron and Delta variant infection. Our findings contrast with the reported lower severity for Omicron variant infection compared with Delta variant infection in immunocompetent individuals.

Multispecies Outbreak of Nocardia Infections in Heart Transplant Recipients and Association with Climate Conditions, Australia.

A multispecies outbreak of Nocardia occurred among heart transplant recipients (HTR), but not lung transplant recipients (LTR), in Sydney, New South Wales, Australia, during 2018-2019. We performed a retrospective review of 23 HTR and LTR who had Nocardia spp. infections during June 2015-March 2021, compared risk factors for Nocardia infection, and evaluated climate conditions before, during, and after the period of the 2018-2019 outbreak. Compared with LTR, HTR had a shorter median time from transplant to Nocardia diagnosis, higher prevalence of diabetes, greater use of induction immunosuppression with basiliximab, and increased rates of cellular rejection before Nocardia diagnosis. During the outbreak, Sydney experienced the lowest monthly precipitation and driest surface levels compared with time periods directly before and after the outbreak. Increased immunosuppression of HTR compared with LTR, coupled with extreme weather conditions during 2018-2019, may explain this outbreak of Nocardia infections in HTR.

COVID-19 Infection in Heart Transplant Recipients: Results of a Six-Month Prospective Survey-Based Study

Solid-organ transplantation recipients were assumed highly vulnerable to coronavirus disease 2019 (COVID-19). However, the results of previous studies in patients with orthotopic heart transplantation (OHT) under immunosuppressive therapy are contradictory. Therefore, we aimed to assess the prevalence of COVID-19 infection and associated risk factors, along with the six-month outcomes in COVID-19 positive OHT patients. This single-center telephone-based survey was conducted on OHT patients. Using a detailed questionnaire, exposure to COVID-19, related symptoms, and preventive self-care measures were collected. Outcomes of COVID-19-positive patients were reassessed using another survey six months later. 118 OHT patients (male: n=87, 73.7%) were included with a mean age of 45.3±13.1 years. Sixteen patients (13.5%) reported one or more symptoms compatible with COVID-19, of whom 12 (10.2%) tested positive. Our results indicated no statistically significant association between COVID-19 and comorbidities. Poor adherence to self-care measures and contact with positive index cases were both significantly associated with COVID-19 infection (P&lt;0.001). A later six months follow-up showed that two out of 12 (16.6%) COVID-19 positive OHT patients died. There was no statistically significant difference between the prevalence of COVID-19 in our patients compared to Iran’s general population (P=0.152). Non-compliance with personal protective protocols and a history of contact with COVID-19 cases were the most risk factors for COVID-19 infection in OHT patients.

Delayed Neutropenia in Heart Transplant Recipients Following COVID-19 Diagnosis

Introduction`Neutropenia is observed after heart transplantation due to medication effects and viral infections. SARS-CoV-2 infection, which causes Covid-19 illness, can uncommonly cause neutropenia in non-transplant recipients. Delayed neutropenia following SARS-CoV-2 infection in heart transplant recipients (HTRs) has not been described.Case ReportCase 1: A 45 year old male combined heart and liver transplant recipient was diagnosed with Covid-19 17 months after transplant. Neutropenia had been noted six months after transplant in the setting of valganciclovir and mycophenolate mofetil (MMF) use, which resolved with discontinuation of those medications. At the time of his Covid-19 diagnosis, his immunosuppression regimen included tacrolimus with a target level 8-10 ng/mL and prednisone 5 mg once daily, and he had an asymptomatic course. His absolute neutrophil count (ANC) four weeks prior to Covid-19 diagnosis was 1,690/uL. The ANC obtained nine weeks after Covid-19 diagnosis was 890/uL. Testing for cytomegalovirus was negative and no neutrophil-depleting medications were identified. He received two doses of granulocyte colony stimulating factor (G-CSF). The subsequent ANC two days after the second dose was 3,600/uL. Case 2: A 66 year old male HTR was diagnosed with Covid-19 31 months after transplant. His symptoms included fever, cough, and diarrhea and he was admitted for inpatient care. Immunosuppression at the time of diagnosis included tacrolimus with a target level of 8-10 ng/mL and MMF 1000 mg twice daily, which was later decreased to 500 mg twice daily. The ANC nadir during his acute illness was 1310/uL. Six weeks after Covid-19 diagnosis, his ANC was 420/uL. Testing for cytomegalovirus was negative. The patient required a total of six doses of G-CSF over six weeks due to persistent neutropenia. MMF was discontinued. He was referred to a hematologist for persistent neutropenia. A bone marrow biopsy showed normal neutrophil production, and increased peripheral neutrophil consumption was hypothesized.SummaryAcute viral infections including SARS-CoV-2 can cause neutropenia, but delayed neutropenia is rare and has not been described in HTRs. Careful monitoring of the complete blood count (with differential) may be useful in this population following a Covid-19 diagnosis. Modulation of immunosuppression and G-CSF administration can support neutrophil recovery.

COVID Infection in Heart Transplant Recipients: Experiences from an Epicenter

PurposeHeart transplant (HT) recipients are at significant risk from Covid-19 infection due to immunosuppression and potential effects on graft function. Currently no standard care management strategy exists for this population. We sought to describe our experiences as a single center caring for HT recipients with Covid-19 infection.MethodsRetrospective chart review of 250 adult HT recipients followed at the University of Southern California identified 46 individuals with PCR-proven Covid-19 infection between March 1st, 2020 and October 1st, 2021. Herein, we report on their baseline clinical characteristics, serial echocardiographic parameters, laboratory values and pharmacologic treatment regimens.Results46 HT patients were identified with Covid-19 infection. Patients were more likely to be male (74%), with a mean age of 52.0 years old, and average BMI of 28.71. The most common indications for HT included NICM (54%) and ICM (22%), and comorbidities included HTN (59%), HLD (59%), DM (39%), and CAD (26%). Over a third of patients (37%) had a history of smoking, and 7 patients (15%) were vaccinated against Covid-19. Patients were on average 6.53 (1.1-9.0) years post-transplant, and on three 3 classes of immunosuppressive medications (89%). The most common presenting symptoms were fever (24%), dyspnea (33%), hypoxic respiratory failure (26%), and GI symptoms (20%). Only 8 patients (17%) had evidence of graft injury with mean donor-derived cell free DNA levels of 0.41 (NL <0.12). Mean EF was 60.7% pre- and 59.0% post-infection. The most common treatment was supportive therapy (39%), followed by monoclonal antibody therapy (28%), steroids (24%; dexamethasone or solumedrol) and antibiotics (24%). Reduction in antimetabolites (33%), calcineurin inhibitors (15%), and prednisone (15%) was common. Half of the patients were admitted to the hospital with 11% requiring ICU level of care, and half were managed as outpatients. Only 4 patients died (1 from non-covid related illness 6 months post-infection) yielding a 91% overall survival rate.ConclusionIn a single-center experience over 18 months, 46 HT patients had proven Covid-19 infection. Overall survival was 91% with mainstays of treatment focusing on supportive care and monoclonal antibody therapy. Further research is needed to clarify optimal treatment strategies in HT patients with Covid-19 infection.

Risk Factors for Invasive Fungal Infections in Heart Transplant Recipients

<h3>Purpose</h3> Heart transplant (HT) recipients are at risk for invasive fungal infection (IFI), a potentially fatal complication. However, data on predictors of IFI in this patient population are sparse. Our goal was to identify pretransplant and posttransplant risk factors for IFI after HT. Additionally, we sought to assess overall survival and one-year mortality among patients with or without IFI. <h3>Methods</h3> We conducted a retrospective, case-control study in consecutive HT recipients at a single center between 2/1/2014-3/31/2020. Electronic medical records were reviewed to collect the following: demographics, peri-operative and operative characteristics, IFI diagnosis, and mortality. We included IFI cases that were classified as probable or proven according to EORTC/MSG criteria. Statistically significant variables in the univariate analysis were introduced into a multivariate logistic regression model using backward stepwise selection to identify predictors of IFI. The impact of IFIs on overall survival and one-year mortality were assessed using Kaplan-Meier estimation. <h3>Results</h3> We identified 25 cases of IFI among 248 HT recipients, occurring at median 79 days (IQR 15-303 days) following HT. Significant risk factors for IFI on multivariate analysis included an increased length of postoperative intensive care unit (ICU) stay (OR 1.07, 95% CI 1.02-1.12), pretransplant hemodialysis (OR 3.83, 95% CI 1.05-12.58), and African American race (OR 3.18, 95% CI 1.08-8.79). The cumulative incidence of IFI was 10.1%. IFI was associated with death (HR 3.28, 95% CI 1.41-7.64, <i>p</i>=.004) and 1-year mortality (HR 7.16, 95% CI 2.48-20.65, p<0.001). <h3>Conclusion</h3> Identification of local risk factors will allow us to develop a targeted antifungal prophylaxis protocol. Hemodialysis and longer ICU stays have been associated with IFI in other studies as well but the association with African American race is new and must be validated. Optimal strategies addressing antifungal prophylaxis and risk reduction for IFI need to be addressed to improve patient outcomes and survival.

Breakthrough COVID-19 Infections in Heart Transplant Recipients: A Case Series

PurposeHeart transplant (HT) recipients are at high risk for Covid-19 infection, and data are limited about the efficacy of vaccination in this unique population. We sought to describe the presentation and outcomes of a cohort of HT patients with Covid-19 infection despite prior vaccination.MethodsRetrospective chart review of 250 adult HT recipients followed at the University of Southern California identified 7 individuals with PCR-proven Covid-19 infection after full vaccination (no patients received booster doses) between December 1st, 2020 and October 1st, 2021. Baseline clinical characteristics, serial echocardiographic parameters, laboratory testing, medication regimens, clinical presentation and clinical course were collected.ResultsA total of 237 were vaccinated with an incidence of 7 breakthrough infections (3%). Patients were predominantly male (71%) with a median age of 50 years old. The average BMI was 32.89. Hypertension (86%), diabetes (57%), and hyperlipidemia (43%) were common. Nearly all (71%) of patients were on 3 classes of immunosuppressive therapy, and nearly half (43%) had a history of rejection. Five patients (72%) received Pfizer-BioNTech, 1 patient (14%) received Moderna, and 1 patient (14%) received the Johnson & Johnson vaccination. One patient had a prior history of Covid-19 infection before vaccine availability. Patients were on average 6.74 (3.8-8.4) years out from transplantation. The most common presentation was dyspnea (71%), cough (57%), and fever (43%). Seventy one percent were hospitalized, and 29% were admitted to the ICU. Treatments varied, with equal rates of antibiotics (29%), steroids (29%), and remdesevir (29%). However the most common treatment was monoclonal antibody therapy (57%). One patient, vaccinated with a single Johnson & Johnson shot, died lending an 86% survival rate for breakthrough infections after Covid-19 vaccination.ConclusionIn a single center experience 7 patients with a history of heart transplant and breakthrough Covid-19 infection were identified and found to have an 86% survival rate. Further investigation is needed assessing the efficacy of the Covid-19 vaccination in this population, as well as evaluation for differential outcomes between the various vaccine options.

SARS-CoV-2 infection in heart transplant recipients: a systematic literature review of clinical outcomes and immunosuppression strategies.

The impact of SARS-CoV-2 infection on heart transplant recipients is unknown. Literature is limited to case reports and series. The purpose of this study is to identify the clinical features, outcomes, and immunosuppression strategies of heart transplant recipients with COVID-19 infection. A systematic review was conducted using the search term “Coronavirus” or COVID,” “SARS-CoV-2,” “cardiac transplantation,” and “heart transplant.” Case reports and retrospective studies were gathered by searching Medline/PubMed, Google Scholar, CINAHL, Cochrane CENTRAL, and Web of Science. Thirty-three articles were selected for review. We identified 74 cases of SARS-CoV-2 infection in heart transplant and heart-kidney transplant recipients. The mean age was 60.5 ± 15.8 years, and 82.4% were males with median time from transplant of 6.5 years. Commonest symptoms were fever, cough, and dyspnea, but new left ventricular (LV) dysfunction was rare. Leukocytosis, lymphopenia, elevated inflammatory markers, and bilateral ground-glass opacities were common. Mortality was high, with particularly poor survival in patients who required intensive care unit (ICU) admission and older patients. Immunosuppression involved discontinuation of antimetabolites and steroids. COVID-19 infection in heart transplant (HT) recipients presents similarly to the general population, but new onset of LV dysfunction is uncommon. Immunosuppression strategies include increase in corticosteroids and discontinuation of antimetabolites.

Outcomes of COVID-19 infection in heart transplant recipients

Abstract Background Heart transplant recipients may be at increased risk for infection and adverse outcomes from infection with COVID-19. Management of these patients is complex, with limited data and no standard of care. Purpose We sought to describe the incidence and outcomes of COVID-19 infection in patients with a history of heart transplant. Methods Retrospective review of 235 heart transplant patients at a large academic medical center identified 31 patients with laboratory confirmed COVID-19 infection. Laboratory and clinical data were collected from our institution as well as other local hospitals patients had been treated at. Outcomes were followed from March 15, 2020 to March 15, 2021. All data was deidentified. Results In a cohort of 235 heart transplant patients, 31 patients were identified after testing positive for COVID-19 infection. The mean and median age of patients was 51.9 and 56.0 years respectively. 71% of patients were male and 29% of patients were female. The mean and median time from transplant to diagnosis was 6.54 and 6.50 years. Average ejection fraction prior to infection was 60.4%. Seventeen patients (55%) had atherosclerosis, ten patients (32%) had diabetes, fifteen patients (48%) had hypertension, and twelve patients (39%) had a history of smoking. 84% of patients were on three types of immunosuppression and 16% were on two. Eight patients (26%) were asymptomatic, six patients (19%) had acute hypoxic respiratory failure, and two patients (7%) had GI symptoms. Two patients had evidence of graft injury with mean AlloSure (donor derived cell free DNA) levels of 0.61%. Immunosuppressive regimens were decreased in 32% of patients and COVID-19 directed therapies were given in 32% of patients. The most common treatments were remdesevir (5 patients), steroids (3 patients), and bamlanivimab (2 patients). Thirteen patients (42%) were hospitalized and two patients (7%) died. Conclusions In a single center case series 31 patients were identified with COVID-19 infection. Nearly half of the patients required hospitalization, with one third of patients decreasing their immunosuppressive regimen and 7% mortality. Further investigation is needed to determine long term outcomes and optimal therapeutic regimen for COVID-19 in this unique population. Funding Acknowledgement Type of funding sources: None.

Epidemiology, risk factors, and association of antifungal prophylaxis on early invasive fungal infection in heart transplant recipients.

Invasive fungal infection (IFI) in heart transplant recipients is associated with poor outcomes. Estimated risk of 1-year IFI in heart transplant recipients is 3.4-8.6% with risk factors inconsistently identified in previous studies. The role of antifungal prophylaxis is unclear. The transplant program at Mayo Clinic provides 6 months of universal azole prophylaxis for those heart transplant recipients in Arizona. We sought to define risk factors for 1-year IFI and determine the effect of antifungal prophylaxis. We conducted a retrospective cohort study of patients undergoing heart transplantation at Mayo Clinic from January 2000 to March 2019. We analyzed demographics, details of transplant hospitalization, antifungal prophylaxis, and fungal infection. Multivariable Cox analyses were performed to identify risk factors of 1-year IFI and impact of IFI on posttransplant mortality. A total of 966 heart transplant recipients were identified with a median age of 56 years (IQR 47, 62). A total of 444 patients received antifungal prophylaxis. Over 1-year follow-up, 62 patients developed IFI with a cumulative incidence of 6.4%. In multivariable analysis, factors associated with IFI were renal replacement therapy (RRT) (HR 3.24, 95% CI 1.65-6.39), allograft rejection (HR 2.33, 95% CI 1.25-4.34), and antifungal prophylaxis (HR 0.32, 95% CI 0.11-0.96). RRT was also associated with invasive mold infection (HR 3.00, 95% CI 1.29-6.97). RRT and allograft rejection after transplantation are associated with 1-year IFI, and RRT is also associated with invasive mold infection. Antifungal prophylaxis appears to be protective and further study is needed in the heart transplant population.

Infección por SARS-CoV-2 en pacientes trasplantados de corazón. Experiencia en México

BackgroundHeart transplant recipients do not escape SARS-CoV-2 infection, their immunocompromised status puts them at high risk for infection. The clinical severity of presentation is uncertain, its mortality in heart transplant patients has not yet been determined. Material and MethodsObservational, retrospective. From March 2020 to February 2021, heart transplant recipients with qRT-PCR positivity to SARS-CoV-2-2 were gathered. The following variables were assessed: age, sex, time of transplantation at the time of infection, mortality, hospitalization, extra oxygen requirement, comorbidities, and severity of infection. ResultsEight SARS-CoV-2 positive patients were gathered, aged 53.8±7.6 years. One female patient (12.5%) and 7 males (87.5%), mean transplantation time 72.8±38.0 months. Mortality was 12.5% (one patient who was hospitalized).Seven patients were treated at home; 3 (37.5%) required supplemental oxygen.Comorbidities were diabetes mellitus 87.5%, arterial hypertension 87.5%, obesity: 25%, the clinical presentation was severe in 1 patient (12.5%), moderate in 2 (25%) and mild in 5 patients (62.5%). AnalysisSARS-CoV-2 infection in heart transplant recipients presents a mild to moderate clinical picture, despite the comorbidities presented. It could be that theimmunosuppressant taken prior to the surgery confers a protective effect.

Laboratory markers of toxoplasmosis in heart recipients

BACKGROUND. The number of organ transplantation surgeries is growing every year, including heart transplantion. The full spectrum of infections in heart transplant recipients is not well understood. One of the infectious agents that is particularly difficult to recognize is Toxoplasma gondii (T. gondii).&#x0D; AIM: This work determines the informative value of detecting laboratory markers of toxoplasmosis in patients after heart transplantation to identify active forms of invasion.&#x0D; MATERIALS AND METHODS: This investigation studied 121 heart recipients (95 men and 26 women) at different times after transplantation (several days to 12 years). Markers of Toxoplasma invasion were determined in blood sera, namely antibodies of the IgG, IgM, and IgA classes to T. gondii, avidity index of IgG antibodies to T. gondii, and DNA of the pathogen.&#x0D; RESULTS: In 60 patients (49.64.5%) after heart transplantation, markers of Toxoplasma invasion were identified. In 20 (16.53.6%) cases, markers of active invasion were revealed, namely IgM and IgA antibodies to T. gondii in six and 11 patients, respectively, low-grade IgG antibodies to T. gondii in three patients, and DNA of the pathogen in two cases. Based on the totality of studies, it was determined that the disease activity in 75% of cases was due to its reactivation, whereas in the other cases, it was a recent infection. Laboratory signs of toxoplasmosis reactivation occurred mainly during the first year after transplantation, which was probably associated with the intensity of immunosuppressive therapy.&#x0D; CONCLUSIONS: It was revealed that the most compelling studies indicating early signs of toxoplasmosis reactivation include detection of IgA antibodies to T. gondii and DNA of the pathogen. Further joint research is required by clinicians, epidemiologists, and laboratory diagnostics specialists to study the aspects of toxoplasmosis and disease diagnostics and preventionin patients after heart transplantation.

Incidence and Outcomes of COVID-19 Infection in Heart Transplant Recipients: The USC Experience

PurposeHeart transplant recipients may be at increased risk for infection and adverse outcomes from infection with coronavirus (Covid-19). Management of these patients is complex, with no standard of care. We sought to describe the incidence and outcomes of coronavirus infection in this unique population.MethodsRetrospective review of 225 heart transplant patients at a large academic medical center identified 8 patients with laboratory confirmed Covid-19 infection. Laboratory and clinical data were collected from our institution as well as other local hospitals patients had been treated at. Outcomes were followed from March 15, 2020 to October 15, 2020. All data was deidentified.ResultsIn a cohort of 225 heart transplant patients, 8 patients were identified after testing positive for Covid-19 infection. The mean and median age of patients was 49.8 and 42 years respectively. 63% of patients were male, and 37% of patients were female. The median and mean time from transplant to diagnosis was 4.1 and 4.5 years. The rate of infection for recently transplanted patients was 11%. Two patients (25%) had atherosclerosis, three patients (37.5%) had diabetes, and five patients (62.5%) had hypertension. Four of the patients (50%) were asymptomatic, 3 patients (37.5%) had acute hypoxic respiratory failure, and 1 patient (12.5%) had dyspnea not requiring oxygen at time of presentation. Four patients (50%) were admitted for treatment. Two patients were treated with remdesvir, one patient with tocilizumab, and one patient with lenrolimab. Immunosuppressive regimens were altered in five patients with decreased mycophenolate mofetil dosing, two patients with decreased tacrolimus dosing, and one patient with decreased cyclosporine dosing. Two patients (25%) had evidence of graft injury with mean AlloSure (donor derived cell free DNA) of 0.6%, the remainder were within normal limits. Overall our patient experience resulted in zero mortality, and all 4 admitted patients were discharged home safely.ConclusionIn a single center case series 8 patients were identified with Covid-19 infection. 25% of the patients demonstrated evidence of graft injury, and nearly every patient had their immunosuppressive regimen decreased with 100% survival to date. Further investigation is needed to determine long term outcomes and ideal therapeutic regimen for Covid-19 in this unique population.

COVID-19 Infection in a 13-year-old Heart Transplant Recipient in Immediate Post Transplant Period - A Case Report

IntroductionExperience regarding course and outcome of Covid-19 infection in heart transplant recipients is limited. Case fatality rate of 25% of covid-19 infection in adult recipients of heart transplant and mild and self-limited disease in young heart transplant patients have been reported in small case series. We describe a case where a 13 year old patient contracted covid-19 infection on 7th post-operative day after undergoing heart transplant and was subsequently discharged from hospital uneventfully.Case ReportA 13 year old boy, with dilated cardiomyopathy underwent orthotopic heart transplant surgery. In the immediate pre-operative period, the real-time polymerase chain reaction (RTPCR) of nasopharyngeal swabs of both the recipient and the brain-dead organ donor were negative for severe acute respiratory syndrome coronavirus type 2 (SARS CoV 2). The intraoperative and immediate postoperative periods were uneventful. The recipient got weaned off from mechanical ventilation on the 1st postoperative day and O2 support was weaned off on 4th postoperative day. He was put on immunosuppressive regimen consisting of mycophenolate mofetil, tacrolimus and prednisone. On 7th postoperative day, he complained of fever, sore throat and dry cough. Nasopharyngeal swab for RTPCR was sent. It reported positive for SARS CoV 2. He was shifted to isolation facility. He maintained more than 94% saturation on pulse oximetry in room air. Immunosuppressive regimen was continued. He was administered 5-day course of remdesivir. Inotropic support was weaned off on 10th postoperative day. On serial bedside echocardiography, the allograft function was found to be normal throughout. He was kept on prophylactic antimicrobial, antifungal and anti-cytomegaloviral therapy and on prophylactic dose of low molecular weight heparin. There was initial rise in neutrophil lymphocyte ratio (17), C reactive protein (58 mg/l), ferritin (871 ng/ml), D-dimer (1904 ng/ml), Troponin T (227 pg/ml) levels, which gradually came down to within normal limits. He was discharged on 38th postoperative day to a home isolation facility as his RTPCR for SARS CoV 2 was still positive, although he remained completely asymptomatic for the last 21 days.SummaryThe course of Covid-19 infection in the immediate post-transplant period of this young heart transplant recipient was largely uneventful.

1086. Epidemiology, Risk Factors, and Effect of Antifungal Prophylaxis on Early Invasive Fungal Infection in Heart Transplant Recipients

BackgroundInvasive fungal infection (IFI) in heart transplant recipients is associated with increased mortality and poor outcome. Reports have estimated the risk of 1-year IFI to be 3.4-8.6% with renal replacement therapy, delayed chest closure, and reoperation suggested as risk factors. However, the role of antifungal prophylaxis is unclear, though previous studies have suggested a reduced incidence of invasive Aspergillosis. The transplant program in Mayo Arizona provides 6 months of universal azole prophylaxis for Coccidioides, while Rochester and Florida only provide prophylaxis to high risk patients. We sought to define epidemiology and risk factors for 1-year IFI and determine the effect of antifungal prophylaxis.MethodsWe conducted a retrospective cohort study of patients undergoing single-organ heart transplantation at Mayo Rochester, Florida, or Arizona from January 2000 to March 2019. We identified baseline characteristics, details of transplant hospitalization such as need for renal replacement therapy, open chest, reoperation, and operative time, receipt of antifungal prophylaxis, and diagnosis of IFI. Multivariable Cox analysis was performed to identify risk factors of time to 1-year IFI.ResultsA total of 966 heart transplant recipients were identified with a median age of 56 years (IQR 47, 62) and 72% male. 444 patients received antifungal prophylaxis which included 32% fluconazole, 34% itraconazole, 18% voriconazole, 15% echinocandin, and < 1% amphotericin or posaconazole. Over 1-year follow-up, 62 patients developed IFI with a cumulative prevalence of 6.4%. The most common organisms were Aspergillus (50%) and Candida (27%). In a multivariable model, factors associated with 1-year IFI were post-transplant renal replacement therapy (HR 3.34, 95% CI 1.69-6.60; P < 0.001) and antifungal prophylaxis (HR 0.32, 95% CI 0.11-0.96; P=0.042). Operative time, recent hospitalization, open chest, and post-transplant mechanical circulatory support were not associated with 1-year IFI.ConclusionRenal replacement therapy after transplantation is associated with 1-year IFI. Antifungal prophylaxis appears to be protective and further prospective study is warranted to verify this finding.Disclosures All Authors: No reported disclosures