|LETTER TO THE EDITOR
|Ahead of print publication
Accepting donors for heart transplant in the shadow of COVID-19
Sarvesh Pal Singh
Department of Cardio-Thoracic and Vascular Surgery, Cardiothoracic Sciences Center, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||11-May-2020|
|Date of Decision||28-May-2020|
|Date of Acceptance||28-Jun-2020|
Sarvesh Pal Singh,
Room No. 2, 8th Floor, Department of Cardio-Thoracic and Vascular Surgery, C N Center, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
In December 2019, many patients died in China due to an unknown cause later attributed to the discovery of a novel coronavirus, SARS-CoV-2. The disease caused by SARS-CoV-2 was labeled as coronavirus disease 2019 (COVID-19). On March 11, 2020, the WHO declared the spread of COVID-19 as a pandemic, leading to most countries entering the lockdown mode. The organ transplant program is also affected by this pandemic in an unprecedented way. For better utilization of resources in the face of a pandemic, nonemergent surgeries, including transplants, were suspended all over India. However, with the WHO cautioning that COVID-19 is “here to stay,” the heart transplant program needs to emerge out of it. It is beyond doubt that the post-COVID-19 world will be different from as we know it.
In India, although there is no accurate data for the number of hearts transplanted annually, the number is approximately between 150 and 200 (unpublished data). The number of lung transplants is far less than the heart. This number is in contrast to more than 1000 kidney and liver transplants performed annually, inclusive of both live and deceased donations. Because of the involvement of lungs in COVID-19, the lung transplant program, post-COVID-19, is going to recover slow and late in India. Furthermore, occasional reports of COVID-19 pneumonia in unsuspected donors have been published. However, there are no published reports of SARS-CoV-2 transmission from donor to recipient yet.
Already a dismal statistic for a population of 1.3 billion people, the revival of the heart transplant program post-COVID-19 will be fraught with challenges in terms of donor availability.
| Availability of Donor|| |
In COVID-19 times, the testing of all organ donors for SARS-CoV-2 with reverse transcriptase-polymerase chain reaction (RT-PCR) is mandatory. It adds to the cost of donor workup. The sensitivity of RT-PCR used to detect SARS-CoV-2 varies with different samples and is between 71% and 93%.,, Therefore, even with negative tests, a remote possibility of the donor harboring SARS-CoV-2 is likely. A nasopharyngeal swab is the recommended sample for testing SARS-CoV-2. However, among all the samples, nasal swabs require the highest viral load (1.4×106 copies/mL vs. 2.6×104 copies/mL for other samples) to return positive. Serum and urine samples are usually negative for the presence of viral nucleic acid, regardless of illness severity. Bronchoalveolar lavage (BAL) samples have been reported positive for patients whose nasopharyngeal swabs were negative for SARS-CoV-2. Performing BAL for all donors is not only invasive but also increases the exposure of health-care workers because of aerosol generation. It requires expertise and Level 3 personal protective equipment, among other precautions to prevent aerosol spread. Therefore, performing BAL may not be feasible at all the donor centers. Endotracheal aspirate by closed suction apparatus may be an alternative to BAL with higher sensitivity (compared to nasopharyngeal swabs) and minimal risk to health-care workers. The antibody tests to detect immunoglobulin (IgM) and IgG antibodies against SARS-CoV-2 are not widely used yet.
In a survey done by the International Society for Heart and Lung Transplantation, the turnaround time for reporting nasopharyngeal samples was <24 h for 55% of patients. A delay in the result for potential organ donors may translate into the hemodynamic deterioration of donors or death. Furthermore, an unsuspected donor who tests positive for SARS-CoV-2 will not only be turned down for organ harvesting but also create new problems for the family members to perform the last rites in unique settings. This fear of extraordinary circumstances may prompt families to opt out of organ donation shortly, restricting the donor pool.
High-resolution computed tomography (HRCT) chest is proving to be a useful screening tool for COVID-19. The sensitivity of HRCT chest, with RT-PCR as a reference, to detect COVID-19 is 97%., Therefore, as an extra precaution, the Indian Society for Heart and Lung Transplantation recommends acquiring an HRCT chest, if possible, before harvesting the heart and necessarily before harvesting the lungs. This recommendation may further shrink the donor pool significantly, especially for lungs, as many donor centers may lack the computed tomography (CT) facility or the logistics to conduct an emergency CT scan even if facilities are available.
An optimal arrangement may be to accept donor hearts by ruling out COVID-19 with the help of clinical picture, RT-PCR for SARS-CoV-2 on endotracheal aspirate, and HRCT chest. When accepting lungs for donation, RT-PCR should be applied to BAL because bronchoscopy is a standard evaluating tool for lungs before harvesting.
In conclusion, to rule out the presence of SARS-CoV-2 in organ donors, the use of BAL as a sample for RT-PCR and HRCT chest may be valuable adjuncts to screen donors more reliably, in the current COVID scenario.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Soin AS, Thiagarajan S. Liver transplant scene in India. MAMC J Med Sci 2016;2:6-11. [Full text]
Patel KJ, Kao T, Geft D, Czer L, Esmailian F, Kobashigawa JA, et al
. Donor organ evaluation in the era of coronavirus disease 2019: A case of nosocomial infection. J Heart Lung Transplant 2020;39:611-2.
Chan JF, Yip CC, To KK, Tang TH, Wong SC, Leung K, et al
. Improved molecular diagnosis of COVID-19 by the novel, highly sensitive and specific 2 COVID -19 - RdRp/Hel real -time reverse transcription-polymerase chain reaction assay validated 3in vitro
and with clinical specimens. J Clin Microbiol 2020;58:e00310-20.
Wang W, Xu Y, Gao R, Lu R, Han K, Wu G, et al
. Detection of SARS-CoV-2 in different types of clinical specimens. JAMA 2020. pii: e203786.
Fang Y, Zhang H, Xie J, Lin M, Ying L, Pang P, et al
. Sensitivity of chest CT for COVID-19: Comparison to RT-PCR. Radiology 2020;200432. doi: 10.1148/radiol.2020200432. Epub ahead of print.
Woolley AE, Mehra MR. Dilemma of organ donation in transplantation and the COVID-19 pandemic. J Heart Lung Transplant 2020;39:410-1.
Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, et al
. Correlation of chest CT and RT-PCR testing in coronavirus disease 2019 (COVID-19) in China: A report of 1014 cases. Radiology 2020:200642. doi: 10.1148/radiol.2020200642. Epub ahead of print.
Gokhale AG, Balakrishnan KR, Punnen J, Kumar RR, Nagamalesh UM, Rahulan KV, et al
. Recommendations of the INSHLT task force for thoracic organ transplant during COVID-19 pandemic in India. Pract Cardiovasc Sci. Available from: http://www.j-pcs.org/preprintarticle.asp?id=283853
. [Last accessed on 2020 May 11].