|Ahead of print publication
Recommendations of the INSHLT task force for thoracic organ transplant during COVID-19 pandemic in India
Alla Gopala Krishna Gokhale1, KR Balakrishnan2, Julius Punnen3, R Ravi Kumar4, UM Nagamalesh5, K Vijil Rahulan6, Chintan Sheth7, Sarvesh Pal Singh8, Sandeep Seth9
1 Department of Cardiothoracic Surgery, Apollo Hospitals, Hyderabad, Telangana, India
2 Department of Cardiothoracic Surgery, MGM Hospital, Chennai, Tamil Nadu, India
3 Department of Cardiothoracic Surgery, Global Hospital, Bengaluru, Karnataka, India
4 Department of Cardiology, MGM Hospital, Chennai, Tamil Nadu, India
5 Department of Cardiology, MS Ramaiah Narayana Heart Centre, Bengaluru, Karnataka, India
6 Department of Pulmonary Medicine and Critical Care Medicine, Gleneagles Global Health City, Chennai, Tamil Nadu, India
7 Department of Cardiac Anesthesia, CIMS Hospital, Ahmedabad, Gujarat, India
8 Department of Cardiothoracic Surgery, AIIMS, Delhi, India
9 Department of Cardiology, AIIMS, Delhi, India
|Date of Submission||23-Mar-2020|
|Date of Decision||23-Apr-2020|
|Date of Acceptance||24-Apr-2020|
|Date of Web Publication||06-May-2020|
Alla Gopala Krishna Gokhale,
Apollo Hospitals, Hyderabad, Telangana, India
Source of Support: None, Conflict of Interest: None
The emergence of COVID-19 has impacted heart transplantation worldwide. The pandemic has impacted donor availability and also raised issues of safety of receipients and surgical teams. In these recommendations, the Indian Society of Heart and Lung Transplantation (INSHLT) has discussed the issues related to the testing and safety issues related to the donor and the recipient as well as the surgical teams. The INSHLT recommends COVID-19 testing once consent for organ donation is obtained of both the donor and the receipient. The INSHLT also recommends high-resolution computed tomography of the chest before organ donation, especially for lung donation.
Keywords: COVID-19, guidelines, heart transplant, organ transplant
|How to cite this URL:|
Krishna Gokhale AG, Balakrishnan K R, Punnen J, Kumar R R, Nagamalesh U M, Rahulan K V, Sheth C, Singh SP, Seth S. Recommendations of the INSHLT task force for thoracic organ transplant during COVID-19 pandemic in India. J Pract Cardiovasc Sci [Epub ahead of print] [cited 2020 Aug 13]. Available from: http://www.j-pcs.org/preprintarticle.asp?id=283853
All Authors are Members of INSHLT Task Force
| Introduction|| |
In December 2019, a number of unexplained deaths occurred in the city of Wuhan in the People Republic of China. Later, these deaths were attributed to a new strain of coronavirus called SARS-CoV-2 or novel coronavirus. In January and February 2020, this virus spread throughout the world causing thousands of deaths. The World Health Organization on March 11, 2020, declared the situation as pandemic following which there has been shutdown of normal activities and businesses. The Indian Society of Heart and Lung Transplantation (INSHLT) taking due cognizance of the situation constituted a task force on March 29 to the draft recommendations for thoracic organ-transplant activity during the COVID-19 pandemic in India.
| General Recommendations|| |
At present, there is no evidence to suggest that heart- and lung-transplant recipients are at increased risk for contracting SARS-CoV-2 virus., The experience of Ren at al. on 87 heart-transplant patients from Wuhan, China, does not indicate a higher COVID infection. There are insufficient data to suggest that, if infected, thoracic-transplant recipients develop more severe disease. Therefore, the INSHLT does not necessarily recommend a general cessation of all thoracic-transplant activity in India during the COVID-19 pandemic. The emergency need of an end-stage heart–lung disease patient has to be weighed against logistical challenges of transporting a donor organ and the risk of SARS-COV-2 transmission from donor to recipient.
| Recommendations for Waitlisted Patients|| |
- Testing is recommended for a waitlisted patient who has a contact history with SARS-CoV-2-positive patient/healthcare personnel in the past 2 weeks
- Testing is recommended for a waitlisted patient who has symptoms of fever, cough, chest pain, shortness of breath, fatigue, and other symptoms consistent with COVID-19 disease
- At present, no prophylaxis is recommended for waitlisted patients
- Any waitlisted patient who tests positive for SARS-COV-2 should be taken off the waiting list and placed in quarantine for a minimum of 14 days. The transplantation should be deferred for a minimum duration of 14 days in asymptomatic patients and, if required, more in case of symptomatic patients. The recipient should be waitlisted again only when he/she tests negative at two occasions 48 h apart.
| Recommendations for Donors|| |
Transmission of SARS-CoV-2 from donor to recipient has not yet been reported but is conceivable. The risk of virus transmission must be balanced against the risk to the recipient, associated with not using the organ and losing an opportunity for transplant.
Donors with a history suggestive of increased probability of SARS-CoV-2 infection should be to be avoided.
High-risk donor groups for COVID-19
- Travel to or residing in an area/HOTSPOT in the preceding 14 days, where local SARS-CoV-2 transmission is occurring
- Exposure to a confirmed or probable case of COVID-19 within the past 14 days
- Compatible clinical syndrome regardless of known exposure within the past 14 days.
The INSHLT recommends that all donors should be tested for SARS-CoV-2 once consent for organ donation is obtained. The testing may be done at the time of testing other viral markers. We recommend reverse transcriptase polymerase chain reaction (RT-PCR)-based donor testing for SARS-CoV-2 using the nasopharyngeal or oropharyngeal swabs or bronchoalveolar lavage fluid. The permission for COVID-19 testing should be automatically granted by all ZTCCs/SOTTOS to donor hospitals. The INSHLT also recommends that donor COVID-19 test be done free of cost (if possible) at the nearest government testing center. Thoracic organ harvesting should be withheld in a COVID-19-positive donor.
A high-resolution computed tomography (HRCT) scan may show signs of SARS-CoV-2 infection even before the development of symptoms or positive RT-PCR and hence may be useful in donor assessment. Therefore, the INSHLT recommends that HRCT chest is desirable in all organ donors as a means of extra precaution and necessary for potential lung donors.
The INSHLT recommends that transplant teams should discuss the risks and benefits of performing transplant with the recipient (and his family/attendants) and high-risk COVID video consent to be obtained from the recipient family.
| Recommendations for Recipients|| |
Patients with end-stage heart and/or lung failure for whom transplant is necessary and unavoidable, we suggest proceeding with transplantation under following conditions for the recipient:
- Absence of recent exposure to either COVID-19-positive patient, such patient's attendant, or healthcare worker
- Absence of travel to any COVID high-risk state/country in the past 2 weeks
- Absence of symptoms compatible with COVID-19 in the previous 2 weeks.
In case of suspicion, we recommend RT-PCR-based testing for SARS-CoV-2 to be performed before transplant and repeated before (24 h or less) intended transplant.
In COVID-negative patients, the INSHLT does not recommend any change in immunosuppression induction protocols and alteration of immunosuppressive drugs and doses. In patients who become COVID positive at a later stage, it is recommended to stop antimetabolite drugs and decrease the dose of calcineurin inhibitors. No dose adjustment is recommended for steroids.
The INSHLT recommends COVID-19 testing for all patients on extracorporeal membrane oxygenation before heart or lung transplant on two separate occasions. It is recommended to avoid thoracic organ transplant in COVID-19-positive patients.
| Routine Biopsies and Visits|| |
Routine biopsies may be deferred for 2–3 months in asymptomatic recipients. Routine visits may be prevented by giving consultations on telephone.
| Prophylaxis for Healthcare Worker|| |
Same as recommended by the ICMR.
| Data Collection|| |
The INSHLT requests that all centers performing cardiothoracic transplantation and VADs collect key data of the course of disease in recipients who develop COVID-19 and share it with SOTTOs and NOTTO, for Future Scientific analysis.
These data should include:
- Gender and age
- Transplant date
- Date of proven COVID-19 infection
- Date of hospital admission
- Date of organ replacement therapy or ventilatory support
- Specific treatment (if any)
- Change to immunosuppression (if any)
- Laboratory tests
- COVID-19 PCR testing report.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ren Z, Hu R, Wang Z, Zhang M, Ruan Y, Wu Z, et al
. Epidemiological and clinical characteristics of heart transplant recipients during the 2019 Coronavirus outbreak in Wuhan, China: A descriptive survey report. J Heart Lung Transplant 2020. doi: https://doi.org/10.1016/j.healun.2020.03.008