Pediatric Heart Transplant Outcomes Using Coronavirus Disease 2019-Positive Donors in the United States

Little is known about the impact of prior coronavirus disease 2019 (COVID-19) infection in an organ donor on the viability of the donor hearts in recipients less than 18 years of age. In a national cohort, we assess whether COVID-19+ donor status impacts outcomes after cardiac transplantation in recipients less than 18 years of age.

We performed a retrospective review of the United Network for Organ Sharing databases of all heart transplant recipients less than 18 years of age, since the inception of COVID-19 data collection (April 2020-December 2024). A COVID-19+ donor was defined as "ever having a positive upper or lower respiratory SARS-CoV-2 nucleic acid amplification or antigen test within 21 days of Recovery." We used a nearest neighbor 1:1 propensity score match to adjust for differences between recipients of COVID-19+ and non-COVID-19+ donor hearts.

Among 2245 pediatric heart transplants, 100 (4.5%) used COVID-19+ donor hearts. These recipients had lower body mass index (16.8 vs 17.8 kg/m², P = .02), but were otherwise similar in age (6 vs 8 years, P = .09) and congenital heart disease prevalence (53% vs 51.5%, P = .85). In matched analyses of COVID-19+ vs non-COVID-19+, rates of postoperative stroke (1% vs 5%, P = .22), dialysis (8% vs 6%, P = .78), and acute rejection (9% vs 14%, P = .39) did not differ between groups. COVID-19 was not reported as a cause of death in any patients who died with a transplanted COVID-19+ heart. Survival at 1 year after transplant was 91.9% (95% CI, 86.2%-97.9%) for COVID-19+ donors and 93.2% (95% CI 88.1%-98.6%) for non-COVID-19+ donors (log-rank P = .71). COVID-19+ donor status was not associated with increased 1-year mortality (odds ratio, 0.88; 95% CI, 0.36-1.85; P = .76).

Recipients of heart transplants less than 18 years of age from COVID-19+ donors demonstrated outcomes comparable to recipients of heart transplants less than 18 years of age from non-COVID-19+ donors. These findings support the safe use of COVID-19+ donor hearts in recipients less than 18 years of age, although longer follow-up is needed.