Clinical outcomes after COVID-19–positive donor heart transplantation in a pediatric population
When the COVID-19 pandemic began, the International Society of Heart and Lung Transplantation did not recommend using COVID-19–positive (COVID+) donors in heart transplants due to concerns over viral transmission and poor outcomes. Since that time, the recommendation has evolved to using COVID+ heart donors selectively. Several studies of adults have reported differences in outcomes and mortality using COVID+ heart donors. Due to the limited availability of donor hearts for pediatric patients and longer waitlist times, it is important to gain an understanding of whether COVID+ heart donors provide a safe alternative and whether such hearts offer a high level of efficacy in pediatric heart transplant recipients. The authors conducted a study to compare outcomes between pediatric heart transplant recipients who had COVID+ versus COVID− donors. The primary outcome was all-cause mortality. Secondary outcomes included graft failure and size mismatch. The authors hypothesized that there would be no significant difference in mortality for COVID+ donor heart transplant recipients. For their retrospective cohort study, the authors queried the Organ Procurement and Transplant Network’s Standard Transplant Analysis and Research (STAR) database for pediatric patients (younger than 18 years old) undergoing heart transplantation between Jan. 1, 2020 and Sept. 29, 2024. The authors excluded donors who did not undergo COVID-19 testing and those who had pending or indeterminate results. Of 2,001 transplant recipients tested, 69 tested positive on a nucleic acid amplification, antigen, or “other” COVID-19 test, and 1,932 tested negative on all COVID-19 tests performed. Only donors that tested positive within seven days of transplant were included in the COVID+ group (n=60). And only patients with negative nucleic acid amplification tests, the gold standard for COVID-19 diagnostic accuracy, were included in the control cohort (n=1,918). The authors also retrospectively collected baseline variables for demographic, perioperative, and posttransplant characteristics for recipients and donors. To account for donor-recipient size mismatch, height ratio was used as the primary metric. The study showed that recipients of COVID+ hearts were on average younger (5.7 versus 7.6 years, P=.019), received organs from greater average distances (360 versus 303 miles, P=.044), and had greater peritransplant extracorporeal membrane oxygenation use (P<.047). Mortality did not differ at six months, one year, or 1.5 years, but cumulative mortality at two and three years was greater in recipients of COVID+ unmatched and matched transplants. At three years, survival was 71.5 percent for recipients of COVID+ versus 86.3 percent for recipients of COVID− hearts. Of note, graft failure was a rare cumulative risk but was insignificant. Mortality risk for COVID+ donor heart recipients was amplified with height mismatch (P=.048). The authors caution that until more data have been accrued, transplant teams for pediatric patients should continue to be selective in accepting hearts from donors who are COVID+. Heightened vigilance is necessary, in particular for children with high pretransplant acuity, significant donor-recipient size mismatch, or multiple marginal donor features.
Zubair MM, Shah AD, Veerakumar E, et al. Clinical outcomes after COVID-19–positive donor heart transplantation in the United States pediatric population. J Thorac Cardiovasc Surg. 2025. doi.org/10.1016/j.jtcvs.2025.12.022
Correspondence: Dr. Edo K. Bedzra at [email protected]