Evolving Long‐Term Outcomes of Heart Transplantation Using COVID‐19 Positive Donors

BACKGROUND: As COVID-19 becomes endemic, evaluating COVID-19+ donors for heart transplantation (HT) remains important. We assessed long-term outcomes using national data and propensity-matched analysis. METHODS: All adults (>18 years) undergoing HT between 4/2020 and 9/2024 were identified in the UNOS database. They were stratified into COVID-19+ versus -, defined by either a positive nucleic acid or antigen test within 7 days of HT. Groups were then 3:1 nearest propensity score matched. Survival was estimated by the Kaplan-Meier method. Mortality risk was assessed using Cox regression models. RESULTS: A total of 879 recipients of COVID-19- hearts were matched with 293 recipients of COVID-19+ hearts. We found no significant differences in 3-year landmark survival between cohorts (p = 0.23). Rates of acute rejection (p = 0.15), length of hospital stay (LOS) (p > 0.9), and postoperative stroke (p = 0.53) did not differ significantly between groups. However, dialysis (17% vs. 12%, p = 0.04) and primary graft dysfunction rates at 24-h post-HT were significantly higher in COVID-19+ heart recipients (5.5% vs. 1.8%, p = 0.01). Donor COVID-19+ status was not significantly associated with mortality risk (HR 1.01, p = 0.66). COVID-19+ donor HTs in recent years (2022-2024) were associated with decreased mortality risk (HR 0.82, p = 0.02), rates of acute rejection (p < 0.001), LOS (p = 0.01), and dialysis (18% vs. 8.9%, p = 0.03). CONCLUSIONS: COVID-19+ hearts demonstrate adequate long-term outcomes, particularly in recent years. Future studies should assess the impact of donor vaccination to optimize survival benefits.