Expanding heart transplant in the era of direct-acting antiviral therapy for hepatitis C

1. The rate of hepatitis C virus (HCV) transmission from nucleic acid amplification testing (NAT)-negative donor hearts is low, and survival rates in patients with donor-derived HCV are high.

Evidence Rating Level: 2 (Good)

While there have been considerable advances in heart transplantation, more and more patients are becoming reliant on mechanical circulatory support (MCS) and are subject to increasing morbidity and mortality due to long wait times and a shortage of donor hearts. Studies examining the use of hepatitis C virus (HCV)-positive donors had previously demonstrated a high rate of HCV infection and poor outcomes in recipients. With the introduction of direct-acting antivirals (DAAs), however, there is renewed interest in using organs from HCV-positive donors. In this prospective cohort study, 80 patients that received a heart transplant from an HCV-positive donor (September 2016-April 2019) at a large academic center were followed up to determine whether the inclusion of HCV-positive donors increased the donor pool, impacted waitlist duration, and to better understand the transmission and cure of donor-derived hepatitis C, morbidity and mortality at 1 year post-transplant. Researchers found that the median active waitlist time from the time of consenting to accept a HCV-positive donor heart was 4 days (IQR 1 to 18 days). Of the patients that had accrued active waitlist time before being consented to receive an HCV-positive donor heart, the median waitlist time was 28 days (IQR 6 to 168 days). The transmission rate of HCV in patients that received a nucleic acid amplification testing (NAT)-positive donor heart was 95.7%. None of the 10 recipients of hearts from NAT-negative donors developed infection. Among the recipients with donor-derived HCV (dd-HCV), 30-day and 1-year survival rates were 92.5% and 90.4%, respectively. This study therefore shows that with the availability of DAAs, the use of HCV-positive donor hearts may serve to expand the donor pool, reducing waitlist times and cardiac-related mortality.