In an observational case series of 80 patients who underwent heart transplant using hearts from hepatitis C (HCV)–positive donors, it has been shown that short-term (30-day) and long-term survival (1-year) of recipients testing positive for HCV exceeds 90% and is not significantly different to that of patients receiving heart transplants from HCV negative donors.
Results of the study titled “Expanding Heart Transplant in the Era of Direct-Acting Antiviral Therapy for Hepatitis C” were published in JAMA Cardiology. Dr. Kelly H. Schlendorf, MD (Vanderbilt University Medical Center, Nashville, Tennessee) and colleagues analyzed data from 80 patients (median age, 54.5 years; 71% men; 69% white) who underwent heart transplants with HCV-positive donors between September 2016 and April 2019. The authors found that the median active wait-list time from the time patients consented to accept HCV-positive donor hearts was 4 days (interquartile range [IQR], 1-18) versus 28 days (IQR, 6-168) for patients before providing consent. This was significantly lower than the national reported median wait times between 70 and 535 days.
The investigators categorized HCV positive donors into two groups: viremia positive and viremia negative (as determined by nucleic acid amplification test [NAAT]). Those with presence of viremia, a total of 70 donors had 95.7% transmission rate of HCV to their recipients, while none of the 10 recipients of hearts from NAT-negative donors developed infection (transmission rate, 0%). In patients testing positive with donor-derived HCV (ddHCV) 30-day and 1-year patient survival rates were 92.5% and 90.4%, respectively. A total of 6 (8.5%) patients with ddHCV died (5 due to primary allograft rejection and 1 due to development of pulmonary embolism). In addition, in the ddHCV cohort, 10 (14.9%) had acute cellular rejection and 1 patient (1.5%) had a single antibody-mediated graft rejection. Length of hospital stay and readmissions of ddHCV recipients were not significantly different from those who received heart transplants from HCV negative donors (median length of stay 15 days vs. 17 days, respectively; P = .79 for difference). Similarly, rates of coronary allograft vasculopathy in recepients also did not reveal any difference regardless of HCV positivity in donors. However, the authors noted that the recipients of transplants from HCV-positive donors exhibited significantly higher rates of severe primary graft dysfunction than recipients of transplants from HCV-negative donors (13.7% vs 3.1%; P = .002). Recipients suffering from ddHCV received direct anti-virals combinations using either Ledipasvir-sofosbuvir (90 mg-400 mg), Sofosbuvir-velpatasvir (400 mg-100 mg) or Glecaprevir-pibrentasvir (100 mg-40 mg) for 12 weeks. It was found that sustained virologic response at 12 weeks was 100% for ddHCV positive recepients.
Extended periods of wait-times for patients requiring heart transplants leads to significant morbidity and mortality. It has been shown that atleast 10% of patients requiring heart transplants die due to long wait-list times and the numbers get worse as wait times increase further. Results from the current study indicate that in the current era of direct acting anti-virals for HepC treatment, heart transplants from HepC positive donors is a viable option for expansion of donor pools and reduce wait list times for those awaiting transplants. Nevertheless, results from this study need to be interpreted with caution due to its limitations. The study was done at a single-center with surrounding municipalities that were affected by opioid crisis with an increased load of HepC donors, which may fail to account for geographical differences that exist in other areas.