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The burden of morbidity and mortality from SARS-CoV-2 infection is especially significant in heart transplant patients who are at higher risk for poor outcomes owing to immunosuppression, blunted response to vaccination, and multiple comorbid conditions. Over the last 3 years the therapeutic landscape for COVID-19 has evolved and our drug armamentaria continues to expand. With these advancements comes a time of great hope to mitigate significant illness from SARS - CoV - 2 infection. However, as with many emerging frontiers, the administration of novel therapeutics to a complex patient population remains challenging. We present a patient case encountered at our institution that highlights the need for increased awareness of nuances while managing COVID-19 infection in a heart transplant recipient.

The novel coronavirus disease 2019 (COVID‐19) is a highly infectious and rapidly spreading disease. There are limited published data on the epidemiology and outcomes of COVID‐19 infection among organ transplant recipients. After initial flulike symptoms, progression to an inflammatory phase may occur, characterized by cytokine release rapidly leading to respiratory and multiorgan failure. We report the clinical course and management of a liver transplant recipient on hemodialysis, who presented with COVID‐19 pneumonia, and despite completing a 5‐day course of hydroxychloroquine, later developed marked inflammatory manifestations with rapid improvement after administration of off‐label, single‐dose tocilizumab. We also highlight the role of lung ultrasonography in early diagnosis of the inflammatory phase of COVID‐19. Future investigation of the effects of immunomodulators among transplant recipients with COVID‐19 infection will be important.

Background Optimal valganciclovir dosing for cytomegalovirus (CMV) prophylaxis in solid-organ transplant (SOT) patients on continuous veno-venous hemodialysis (CVVHD) is not known. Ganciclovir trough concentrations ≥0.60 μg/mL have been suggested for CMV prophylaxis. This study was conducted to determine if valganciclovir 450 mg enterally every 24 hours achieves ganciclovir trough concentrations ≥0.60 μg/mL in patients on CVVHD. Methods This single-center, prospective, open-label, pharmacokinetic study included adult SOT patients admitted to an intensive care unit from March 2018 to June 2019 on CVVHD. All patients were receiving valganciclovir 450 mg enterally every 24 hours for CMV prophylaxis prior to enrollment. Each patient had a peak and trough sample drawn at steady state. Results Ten SOT patients were included in the study (6 liver, 1 simultaneous liver-kidney, 2 bilateral lung, 1 heart). The mean ± SD age was 51.8 ± 14.0 years, and average body mass index was 27 ± 6.9 kg/m2. Ganciclovir trough concentrations ranged from 0.31 to 3.16 μg/mL, and 80% of participants have trough concentrations ≥0.60 μg/mL. No patients had documented neutropenia while on valganciclovir and CVVHD; 60% of patients had significant thrombocytopenia. Conclusions Valganciclovir 450 mg enterally every 24 hours achieved ganciclovir trough concentrations ≥0.60 μg/mL in most patients on CVVHD, similar to those reported with intravenous ganciclovir for prophylaxis in this population. Based on these data, valganciclovir may require dosing every 24 hours to achieve concentrations equivalent to ganciclovir. Neutropenia did not occur in the study period. Thrombocytopenia was common and likely multifactorial.

Continuous-flow left ventricular assist device (LVAD) placement has become a standard of care in advanced heart failure treatment. Bleeding is the most frequently reported adverse event after LVAD implantation and may be increased by antithrombotic agents used for prevention of pump thrombosis. This retrospective cohort included 85 adult patients implanted with a Heartmate II LVAD. Major bleeding was defined as occurring >7 days after implant and included intracranial hemorrhage, events requiring 2 units of packed red blood cells within a 24-h period, and death from bleeding. Primary outcome was intensity of anticoagulation between patients with or without at least one incidence of nonsurgical major bleeding. Major bleeding occurred in 35 (41%) patients with 0.48 events per patient year and a median (IQR) time to first bleed of 134.5 (39.3, 368.5) days. The median (IQR) INR at time of bleed was 1.7 (1.4, 2.5). Median INR during follow-up did not differ between groups and patients with major bleeding were not more likely to have a supra-therapeutic INR. Patients who bled were more likely to have received LVAD for destination therapy, to have lower weight, worse renal function, and lower hemoglobin at baseline. Duration of LVAD support and survival were similar between groups with no difference in occurrence of thrombosis. Incidence of nonsurgical major bleeding was not significantly associated with degree of anticoagulation. Certain baseline characteristics may be more important than anticoagulation intensity to identify patients at risk for bleeding after LVAD implant. Modification of anticoagulation alone is not a sufficient management strategy and early intervention may be required to mitigate bleeding impact.

Introduction Compared to enalapril, sacubitril/valsartan reduces mortality and hospitalizations among patients with HFrEF. Spironolactone has shown similar benefits in North Americans with HFpEF. Inpatient initiation of other mortality-improving heart failure medications has been associated with higher rates of use at 6 months of follow-up. The objective of this study was to develop screening criteria for inpatient initiation of sacubitril/valsartan or spironolactone, identify eligible candidates for these therapies, and assess the barriers to initiation during an admission for heart failure. Methods Patients admitted with a diagnosis of heart failure were screened daily to assess current inpatient medications, lab values, and vital signs. Due to concerns about monitoring for hyperkalemia, spironolactone candidates were required to be established patients at the Johns Hopkins Heart Failure Bridge Clinic (HFBC). In the absence of contraindications, the primary team was contacted and a recommendation for initiation was given. Barriers to initiation were documented when candidates failed to receive therapy during the hospitalization. Daily patient screening occurred from November 1, 2017 through February 28, 2018. Results Two-hundred patients were screened during the study period. There were 54 patients (23 with HFrEF and 31 with HFpEF) identified to be eligible for therapy. Of those, one patient was initiated on sacubitril/valsartan and three on spironolactone. Barriers to initiation included prescriber resistance, patient refusal, high copays, and lack of adequate follow up for electrolyte monitoring. One-hundred and forty patients had not been previously seen at the HFBC, and of those, only four had a new patient appointment scheduled upon discharge. Conclusion This study identified several barriers to initiating sacubitril/valsartan for HFrEF and spironolactone for HFpEF during inpatient admission. These findings indicate the need for additional physician and patient education about these therapies, as well as improved coordination of patient care during transition from hospital to home through clinics like the HFBC. Targeting inpatients for initiation of medications should be a priority, as these patients are at high risk for readmission, and inpatient initiation has been associated with higher long-term rates of medication use in HF. Increasing prescribing rates of medications that improve morbidity and mortality in heart failure have positive impact on patient quality of life and ultimately reduce healthcare costs associated with this disease.