Zepatier For Treatment Of Hepatitis C-Negative Patients Who Receive Heart Transplants From Hepatitis C-Positive Donors (HCV)

Inclusion Criteria:

New York Heart Association (NYHA) Class III or IV CHF refractory to maximal medical therapy (ACE inhibitor, B-blocker, digoxin and diuretics, resynchronization therapy or Implantable Cardioverter Defibrillator when applicable) and/or conventional surgery.
Inoperable coronary artery disease with intractable anginal symptoms
Malignant ventricular arrhythmias unresponsive to medical or surgical therapy
18-65 years of age
Obtained agreement for participation from the transplant cardiology team
No evident contraindication to liver transplantation other than the underlying cardiac disorder
Able to travel to the University of Pennsylvania for routine post-transplant visits and study visits for a minimum of 6 months after transplantation
No active illicit substance abuse
Women must agree to use birth control in accordance with Mycophenolate Risk Evaluation and Mitigation Strategy (REMS) following transplant due to the increased risk of birth defects and/or miscarriage
Both men and women must agree to use at least one barrier method of birth control or remain abstinent following transplant due to risk of HCV transmission
Inclusion criteria for treatment (not for entry as study patient) will include any detectable HCV RNA by week 4 post-heart transplantation
Able to provide informed consent

Exclusion Criteria:

Hepatocellular carcinoma
HIV positive
HCV antibody positive and/or RNA positive
Hepatitis B surface antigen, core antibody, and/or DNA positive
Any other chronic liver disease (excluding non-alcoholic fatty liver disease (NAFLD) with abnormal liver enzymes
Persistently elevated liver transaminases
Congenital heart disease
Fibrosis by liver biopsy or total bilirubin > 2.5 with associated evidence of synthetic dysfunction.
Pregnant or nursing (lactating) women
Known allergy or intolerance to tacrolimus that would require post-transplant administration of cyclosporine, rather than tacrolimus given the drug-drug interaction between cyclosporine and ZEPATIER
Waitlisted for a multi-organ transplant
Evidence of end organ damage due to diabetes (e.g. retinopathy, nephropathy, ulcerations) and /or brittle diabetes mellitus (e.g. history of diabetic ketoacidosis) and/or uncontrolled diabetes as evidence by a HgbA1C of 7.5-8.5.
Chronic bronchitis, chronic obstructive pulmonary disease, inability to stop smoking.
Hematologic: Significant coagulation abnormalities, bleeding diatheses.
Psychosocial: Profound neurocognitive impairment with absence of social support.
Active mental illness or psychosocial instability
Inadequate insurance or financial support for post-transplant care.
Evidence of drug, tobacco or alcohol abuse within the past six months and completion of recommended therapy/services or meets satisfied parameters as indicated by social work staff and/or consult team.
History of chronic non-compliance.
Amyloidosis (restricted to cardiac only, without evidence of extra cardiac involvement)
BMI ≥38
Active peptic ulcer disease.
Severe malnutrition.
Major chronic disabling illness (e.g. lupus, severe arthritis, neurologic diseases, previous stroke with profound residual).
Pulmonary infarction within the past 6 weeks
Severe pulmonary hypertension as evidenced by a fixed pulmonary vascular resistance of greater than 4 Wood units on appropriate medical therapy.
Patient refusal to receive blood products or transfusions during heart transplant surgery.
Severe chronic obstructive pulmonary disease
Current clinical sepsis.
Symptomatic or severe vascular disease.
Chronic Kidney Disease Stage IV, Glomerular Filtration Rate < 30
History of Mantle radiation.
Asymptomatic renal cell carcinoma <1 year from curative treatment.
Symptomatic renal cell carcinoma <5 years from curative treatment.
Prostate cancer <2 years from curative treatment.
Uterine or cervical cancer <2 years from curative treatment.
Any other cancer other than the above including malignant melanoma, < 5 years from treatment apart from other skin malignancies.

Donor Organ Selection Criteria:

General criteria (although there can be exceptions on a case-by-case basis)

Detectable HCV RNA
Genotype 1 or 4 HCV
Age <=55 years
No history of coronary artery disease
No congenital heart disease except a repaired atrial septal defect (ASD) provided the patient has normal right ventricular function
No history of arrhythmia (atrial fibrilation, atrial flutter or VT) except during resuscitation from fatal event.
No evidence of cirrhosis

Echocardiographic criteria:

Left ventricular ejection fraction (LVEF) >=50%
Normal right ventricular function
No left ventricular hypertrophy (LVH) - septal wall thickness <1 cm
No left ventricular hypertrophy (LVH)- posterior wall thickness <1 cm
No significant valvular heart disease - more than mild tricuspid regurgitation, more than mild mitral regurgitation, more than trace aortic regurgitation. No mitral or aortic stenosis.
No congenital heart disease - transposition of the great vessels, ventricular septal defect (VSD), ASD, and/or single ventricle (Fontan)

Right heart catheterization criteria:

Right atrial pressure <=10mmHg
Pulmonary capillary wedge pressure <=18mmHg
CI >=2.1 l/min/m2
Pulmonary hypertension is allowed if the patient has normal right ventricular function and a normal tricuspid valve