The world has come to understand the importance of equitable healthcare in the modern era. As a transplant cardiologist, I work hard to delay my patients’ slow march towards death. Unfortunately, I am not always successful. For those who are at the brink of life and death, awaiting heart transplantation, the current COVID-19 pandemic only brings about further uncertainty. With a limited number of organ donors in the United States already stifling opportunities to receive the gift of life, the increased need for protecting health care providers during the pandemic has added to this constraint. Working to help increase stability while awaiting heart transplantation, advancements in temporary support devices and aggressive donor selection have allowed for transplants to continue, however, to a much lesser degree.
As we think about the broad effects of testing, exposure, asymptomatic carriers and risk mitigation – all of these factors are amplified in organ procurement. At the time of organ procurement, a team of around eleven surgeons, surgical techs and nurses descend upon the donor hospital, all in their own personal protective equipment working together for one common goal. Unfortunately, as one can imagine, the uncertainty and lack of testing for COVID-19 has caused a larger number of organs to go unused, not due to their quality per se, but rather as a result of the increased risk to procurement teams.
In addition to limited transplant opportunities and the rapidly changing tide of data surrounding COVID-19, optimization of medical therapy with traditionally ubiquitous drug classes – angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB), has become difficult to navigate. This has mainly been as a result of concerns for increased complications with COVID-19 infection. Current data for ACEi or ARB’s, however, shows limited risk but has not been broadly studied. Due to media coverage and increased scrutiny, however, many patients are not comfortable taking these proven therapeutics. Additionally, the post-transplant risk of infection plays a key role in the early mortality of transplant recipients, with the inhibition of the immune system a mainstay preventing organ rejection. Post-transplant COVID-19 infections have been reported, and within those within the first year of transplantation, the mortality rate exceeds 70%.
As providers, we continue to develop practices, optimize workflows and distribute validated recommendations – while maintaining a focus on evidenced based medicine. Within the field of cardiology, for example, we have seen a surge in stress related cardiomyopathies, increase in viral myocarditis (both COVID and non-COVID), as well as increasing trends of arrhythmias in patients utilizing unproven therapies with underlying cardiac conditions. In the words of the Mayo brothers, “the needs of the patient come first.” Understanding our key role in this challenging time of providing sound guidance with the focus on patient-centered care is key. As with every transplant patient, we hope for the best but plan for the worst.
Rohan Goswami, MD FACP FACC
Senior Associate Consultant – Department of Transplantation
Medical Director – Digital Innovation Lab
Mayo Clinic Florida
Dr. Goswami is a guest writer for InCrowd.
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