Number of Americans taken off heart transplant waitlists amid coronavirus pandemic up by 75%, finds study
The number of heart transplants in the US has dropped sharply amid the coronavirus pandemic, even in areas of the country with few Covid-19 cases, according to an analysis by researchers at the Columbia University Irving Medical Center, New York. This has been accompanied by increased waitlist inactivations, decreased waitlist additions and decreased donor recovery.
Researchers found that waitlist inactivations increased 75% during the coronavirus pandemic driven largely by the Northeast region. The regions with the highest number of inactivations because of Covid-19 were the Northeast (196 or 91%), Southwest (81 or 81%) and Great Lakes (63 or 66%). Of the 600 inactivations, 403 (67%) were reported to be because of Covid-19 precautions. At the same time, at least 37% fewer people were placed on heart transplant waitlists during the pandemic, with the most significant decreases occurring in the Northeast (69% decrease) where Covid-19 case rates were highest, the Great Lakes region, and the Southwest. Only one region, the South Midwest, saw an 8.5% increase in waitlist additions.
“During the Covid-19 era, there were 600 waitlist inactivations compared with 343 during the pre-Covid era (75% increase). Waitlist additions decreased from 637 to 395 (37.9% reduction). These changes were most profound in the Northeast and Great Lakes regions with high rates of Covid-19,” write authors in the study published in JAMA Cardiology. The team also includes researchers from Harvard Medical School, Boston; University of Pennsylvania, Philadelphia; and Cedars-Sinai Medical Center, Los Angeles.
The authors explain that at the beginning of the pandemic, clinicians had to weigh the risks of exposing medically fragile patients with heart failure, though well enough to remain at home, to Covid-19 infection with the risks of delaying a life-changing surgery. Accordingly, many clinicians reacted by taking their patients off the waitlist -- a measure typically pursued when a patient has a health issue that temporarily or permanently disqualifies them for transplantation -- but was expanded during the pandemic to include patients at risk of Covid-19 infection and to accommodate transplant centers that deferred acceptance of donor organs due to the pandemic.
The study analyzed changes in waitlist inactivations, waitlist additions, deceased donor recovery, and transplant volumes from what the authors refer to as the pre-Covid-19 era (January 19-March 15, 2020) to the Covid-19 era (March 15-May 9, 2020).
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The analysis shows the number of heart transplants performed nationwide dropped 26% during the 8 weeks marking the height of the pandemic in the Northeast compared to the prior 8 weeks. “Heart transplant volume decreased by 26% nationally from the pre-Covid-19 era (525 transplants) to the Covid-19 era (389 transplants),” the findings state. Heart transplant volumes were significantly reduced across all regions except the Northwest.
The drop in transplants occurred even in areas with lower infection rates. “We had concerns that the availability of ICU beds and ventilators would impact our transplant patients, particularly in the Northeast. But we were surprised to see a decline in heart transplants in other parts of the country, where there were far fewer Covid-19 cases at that time. Our data show that this pandemic has had far-reaching impacts on the care our patients with advanced heart failure are receiving,” says the first author of the study Ersilia DeFilippis, a postdoctoral clinical fellow in medicine and cardiology at Columbia University Vagelos College of Physicians and Surgeons.
The researchers also found that the availability of donor hearts decreased by 26% from 1,878 to 1,395 during the Covid-19 period compared with the pre-Covid-19 period. The most significant decrease occurred in the North Midwest despite low Covid-19 prevalence. From the pre-Covid-19 era to the Covid-19 era, there was significant regional variation in deceased donor recovery, such as a 41% decrease in the North Midwest versus a 16% decrease in South Midwest.
The team explains that limited access to testing for donors as well as restrictions on organ procurement organizations may have contributed to the decrease we observed in donor recovery. “Based on weekly trends, the number of recovered donors nadired at the end of March. Contributing factors may include concerns regarding Covid-19–positive donors, lack of access to Covid-19 testing to confirm donor Covid-19 status, decreased intensive care unit capacity for treating brain-dead donors. It may also include changes in the rates of unintentional death as a result of social distancing policies, and limitations in the ability of organ procurement teams to operate in the context of Covid-19 –associated policies around hospital access and travel,” says the study.
Based on their findings, the authors say that in addition to challenges regarding safety and resource allocation, changes in behaviors and activity as a result of social distancing measures will continually affect the deceased donor pool. The researchers now plan to study the impact of these changes on patient survival while on the transplant waitlist and post-transplant survival. “We must be prepared for more inactivations and fewer transplants if and when future surges of Covid-19 cases occur. In the coming months, the consequences of these waitlist inactivations and decreased transplant volumes on waitlist mortality must be surveilled,” write authors.