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Share your Experience with COVID-19

  • 1.  Share your Experience with COVID-19

    Posted 03-13-2020 17:26


    We all devour research papers daily hungry for information about Covid-19 and transplant, but I believe that the ISHLT community must move quicker than that to save lives.  Our hearts go out to our colleagues in China, Italy, South Korea and elsewhere who have borne the brunt of the pandemic thus far. 

    I would like to propose this thread for colleagues to post replies on the following topics (feel free to add)

    PRESENTATION---  Chest xray initial pattern? Clinical tempo of deterioration. Only adults or do pediatric transplants develop significant illness

    MANAGEMENT-- If a transplant "looks well" but has COVID-19-- do you admit? How often do these patients deteriorate and if so, is it sudden where they suffer by not being admitted?

    TREATMENT-- Experience with antivirals (beyond trials)--- Ganciclovir?   Treating inflammation with Tociluzumab, chloroquine?

    Co-infection--- Does Influenza + or human metapneumovirus positive rule out COVID?

    IMMUNOSUPPRESSION--- In Kidney forums, some recommend steroid only immunosuppression which is not practical for heart patients. What are people doing? Higher steroid, or cutting steroid off, holding MMF? Perhaps TAC Monotherapy (my bias)

    Please share as we combat this terrible illness.

    David Baran, MD
    Director, Advanced Heart Failure and Transplantation
    Sentara Heart Hospital
    Norfolk, Virginia

  • 2.  RE: Share your Experience with COVID-19

    Posted 03-13-2020 21:08
    Thank you for starting this conversation. I wholeheartedly agree!

    I do have some specific questions as well that has come up within our group in Milwaukee, WI.
    1) We've had patients calling with URI symptoms. In the absence of any known effective treatments, what is the benefit and threshold for COVID-19 testing? Are other programs testing anyone who has a URI (i.e. 'head cold' or a persistent cough) or focusing on higher risk symptoms (fevers and other constitutional symptoms)?

    2) For patients further out from transplant, how have you been approaching routine follow-up visits? Are you pushing visits out an extra 1-2 months to see how the curve of detected cases in your area progresses or are you keeping to routine survellance protocol?

    David Ishizawar, MD
    Advanced Heart Failure/Transplant Cardiology & Pulmonary Hypertension
    Froedtert Hospital and the Medical College of Wisconsin

    David Ishizawar
    Pewaukee WI
    (414) 955-6797

  • 3.  RE: Share your Experience with COVID-19

    Posted 03-14-2020 03:35
    Hallo - so far we have no notice about this disease in any of our HTX recipients. In order to limit their occasions to be infected, we are postponing the appointments of stable pts and checking the status of each scheduled pt with phone calls. They should follow suggestions regarding social restrictions and containment more strictly than any other - although it is not sure how baseline immunosuppression could modify the course and severity of disease which appear in part related to "cytokines' storm". Currently the most interesting approach to treatment (in the immunocompetent host) here seems to be anti-IL-6 tocilizumab. Regarding diagnosis, nasopharyngeal swab is useful when positive but false negative is not uncommon in asymptomatic carriers and in pts with lower respiratory tract infection (for the latter CT scan is useful). Thus generalized protective measures should be implemented according to local conditions and risks - "covid-free" areas and pathways may be created here and there in some hospitals for some categories of pts and/or procedures but you may not be sure that they will remain "free". Cleansing and patients and personnel protection remain essential everuwhere. 

    Maria Frigerio

  • 4.  RE: Share your Experience with COVID-19

    Posted 03-14-2020 08:34
    Any one has change from tac to mTOR?
    It seems to have anti COV effect.

    Piedad Ussetti

  • 5.  RE: Share your Experience with COVID-19

    Posted 03-19-2020 05:10
    Dear Piedad,
    Do you have a reference for the effects of mTOR on coronavirus?

    Are Martin Holm, MD PhD
    Associate Professor
    Oslo University Hospital, Norway
    Chair Scandiatransplant Heart and Lung Group

  • 6.  RE: Share your Experience with COVID-19

    Posted 03-14-2020 01:43
    This is a GREAT idea Dave.

    Will add in the management portion:
    What are implications for acute MCS (ECMO, microaxial flow pumps etc )

    Stay safe and take care of yourself!


    Jaime Hernandez Montfort
    Friendswood TX
    (413) 297-3873

  • 7.  RE: Share your Experience with COVID-19

    Posted 03-14-2020 04:50
    Dear All,
    1) I would also add a section on the impact on the possible effect on organ donations.
    Until now, from the start of the emergency, yesterday we had the first donor offer. I don't know the number on a national basis but we are strongly interested to understand what is happening and what will happen in terms of donor supply as in Italy we have 250 organs for year.
    2) Regarding new cases, we still have not one case too and we are waiting to look at the results of the drug experimentation that started in our hospital on Tociluzumab in patients with high IL-6 levels.
    3) We have reduced the appointments for stable patients in follow-up after HTx and we are reasoning of using checklists and devices to follow-up our HF patients.
    4) How many centers have experience of VV-ECMO in COVID-19 patients?
    Best Regards

    Cristiano Amarelli
    Staff Surgeon

  • 8.  RE: Share your Experience with COVID-19

    Posted 03-14-2020 05:13
    Hi Cristiano and all
    I think it is too early to evaluate the impact of this situation on organ donation. I expect (unfortunately) a negative impact due to 1) the need to pay attention to the living patients in the ICUs (or waiting for a bed in the ICU...) ; 2) the perceived/actual risk of donation from pts who die in the same ICUs that are caring for covid-pts. But anyway, we'll see. 

    Maria Frigerio

  • 9.  RE: Share your Experience with COVID-19

    Posted 03-15-2020 04:19
      |   view attached
    As discussed and then requested by Mark Slaughter and Aly El Banayosy, in terms of not conservative treatment :
    The ratio results to be : 10 (conservative treatment and on ventilator) / 1 VV ECMO (mechanical treatment). This is the same for all Italian centres, I feel (... and I'm checking and collecting data).
    VV ECMO for younger pts crushing (40 to 55 yy/old) and all obese pts having diabetes too.
    Frail and older pts (>65 yy) no ECMO. Only conservative. This would be rescue in our opinion. Conservative is effective as well. 
    Average time of treatment >15 dd (for both conservative and mechanical strategies).
    Yet, no weaning off from ECMO, no deaths, still ongoing (same for pts on ventilator only without ECMO).
    Mostly adoption of lopinavir/ritonavir. Up to 50% even antibiotica. 
    CT-scan, X-chest ray and respiratory function slowly but very slowly improving. They do need more time than expected. This interstitial lung disease is dramatic. Lung are not stiff as ventilator setting needs but the disease in extensive and with high rate of recurrence. Need of prone position frequent and significative.
    We'll see. Let's hope...

    Herein attached COVID-19 selection criteria by Singapore. Potentially useful.

    Dr. Antonio Loforte, MD, PhD

    Bologna S. Orsola University Hospital, Italy

    Antonio Loforte

  • 10.  RE: Share your Experience with COVID-19

    Posted 03-29-2020 10:15
    Dear Cristiano,

    herein attached Euro-ECMO survey for VV and VA ECMO in COVID-19 pandemic.
    We should monitor by ISHLT too, in my opinion.


    Antonio Loforte, MD, PhD

    Bologna S. Orsola University Hospital, Italy
    +39 051 2149043
    +39 338 4395425


  • 11.  RE: Share your Experience with COVID-19

    Posted 03-18-2020 16:53
    Edited by Letizia Corinna Morlacchi 03-18-2020 16:55
    Dear all

    I am a transplant pneumologist, writing from Milan, where we are facing this emergency since the last days of February.

    We have just admitted one of our patients for COVID19 pneumonia. He is a 48 year old male and he received bilateral lung transplant for cystic fibrosis in April 2014. His graft was doing great till January (his last routine visit; his next visit was originally scheduled for April 2020): his FEV1 was 92% of predicted and 97% of best/baseline; excellent performance status. Baseline IST: CS + Tac + eve.
    After a phone call, he was admitted to our ER for fever and malaise; no cough, no dyspnea, no cold. His swab turned positive; his blood test showed lymphocytopenia and mild increase of c-reactive protein. Although no significant alteration of gas exchange was founded, we decided to admit him at our UNIT because of his CT scan (bilateral patchy GGO). We started CPAP during the night for support. Initial treatment included Kaletra and antibiotic regimen with pip/tazo.
    He is currently doing fine, but we are keeping him closely monitored.

    I would also like to add that we had two other lung transplant recipients who were tested for COVID19 (but this happened in the last days of February, when the situation was much less dramatic) for URI; they both turned negative, but influenza virus was founded on their swabs and they received a course of oseltamivir. Hospital admission was not indicated (no pulmonary infiltrate, no respiratory distress/failure). They are currently doing fine.

    I do hope we will be able to cope with this emergency.

    Kindest regards. Stay safe.


    Letizia Corinna Morlacchi, Respiratory Consultant
    U.O.C. Pneumologia Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano

  • 12.  RE: Share your Experience with COVID-19

    Posted 03-19-2020 05:08
    Dear Letizia,
    Thank you for your report.
    Could you please write something about why you choose Kaletra (lopinavir/ritonavir) and if you experienced any interactions with tac or eve? And also: did you continue Tac, eve and cs? (he was already not on MMF or azathio. , right?)
    Finally: are you keeping a local registry of tx patients with COVID-19? It will be useful as number of cases increase.
    Best regards,
    Are Holm
    (tx-pulmonologist, Oslo, Norway)

    Are Martin Holm, MD PhD
    Associate Professor
    Oslo University Hospital, Norway
    Chair Scandiatransplant Heart and Lung Group

  • 13.  RE: Share your Experience with COVID-19

    Posted 03-19-2020 09:51
    Hi! NEJM published a trial yesterday evaluating kaletra vs standard of care in 199 patients admitted with severe COVID-19 in China. No benefit was observed in the kaletra arm (n=99) in terms of days of illness, mortality, and duration of viral shedding. Paper is attached. 

    Also attached is a preprint from France  showing benefit of plaquenil especially when added to azithromycin in a small group of patients, especially in terms of reduction of PCR+ nasopharyngeal samples. Anyone with additional experience with this combo? 


    Saima Aslam, MD, MS
    Associate Professor
    Medical Director, Solid Organ Transplant Infectious Diseases
    Division of Infectious Diseases and Global Public Health
    University of California, San Diego

  • 14.  RE: Share your Experience with COVID-19

    Posted 03-19-2020 14:05
    if anyone has any information regarding mTor and coronavirus - please send 
    thank you
    Wojtek Karolak


  • 15.  RE: Share your Experience with COVID-19

    Posted 03-19-2020 14:55

    The NEJM article on Kaletra was not supportive of its use against COVID as opposed to the Hydroxychlorquine and azithromycin combo


    Raymond L. Benza, MD, FACC

    Professor and Director

    Division of Cardiovascular Diseases

    Bob and Corrine Frick Endowed Chair of Heart Failure

    Department of Medicine

    The Ohio State University Wexner medical Center

    395 W 12th Ave

    Columbus, Ohio 43210

    Office: 614-247-7779

  • 16.  RE: Share your Experience with COVID-19

    Posted 03-19-2020 14:59
    that is a protease inhibitor - no word on mTor (Sirolimus / Rapmune)
    Wojtek Karolak

  • 17.  RE: Share your Experience with COVID-19

    Posted 03-19-2020 15:19
    Hi everyone
    also any news of SEROLOGY testing for COVID-19? IgG and IgM?
    Wojtek Karolak

  • 18.  RE: Share your Experience with COVID-19

    Posted 03-21-2020 06:35
    Edited by Letizia Corinna Morlacchi 03-21-2020 06:35
    Dear Are, dear all

    sorry for the late reply but these are strange days.

    Firstly, I need to post a huge correction to my initial report; I apologise for my sentence wich was misleading.  With reference to "initial treatment": we had asked our local pharmacy for Kaletra (which is not immediately available for every patient, we need to sign papers and then we receive it for each individual within 24-48 hrs), but in the end we decided NOT to admister this drug both because we were afraid of drug interactions and because of the recent evidence from the NEJM trial.
    We decided instead to start hydroxychloroquine.
    Paracetamol (acetaminophen) is currently enough to manage his temperature; his P/F on RA is in 390.

    Secondly, for what concerns IST, we decided to temporarily hold eve, and leave him only on CS and tac.

    We are currently keeping a registry including all the patients we are testing for COVID19.
    In the last 48 hrs, we had another patient tested, who turned negative.
    I would like also to add that our COVID patient (despite being extremely cautios, he never left his house since the end of February, practicing smart working and home sport) lives in the surroundings of two of the hardest hit cities in Lombardy (Brescia and Bergamo).

    Finally, to answer dr. Karolak, we currently have no news regarding availability of serology testing for COVID19.

    Kindest regards


    Letizia Corinna Morlacchi, Respiratory Consultant
    U.O.C. Pneumologia Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano

  • 19.  RE: Share your Experience with COVID-19

    Posted 03-21-2020 06:44
    Hi Letizia,
    Thanks for the reply... it seems this is the way to go in this particular case (quite stable).... please keep us updated.
    Milan is in a tremendous difficult situation I hope you are okay...
    I read that things are so bad - people are not counting the dead - i hope this is not true... 
    in Poland so far no transplant patient with COVID-19
    thanks for the serology info - if anyone has info please send ASAP

    Wojtek Karolak
    Gdansk Lung Transplant Program