High-risk Cytomegalovirus in Heart Transplant: How Can We Improve?

Background: Cytomegalovirus (CMV) infection is associated with worse outcomes after heart transplant (HT). CMV mismatch (donor positive, recipient negative serology, D+/R-) increases the risk of infection. Guidelines recommend 3 to 6 months of antiviral prophylaxis in these patients. An increase in primary CMV infections at our center prompted us to analyses this population in search of improvement.

Methods: From 185 adult HT receptors in 10 years, we selected those with CMV D+/R-. Patients were followed until October 2023. We evaluated the patterns of transmission of CMV in accordance with current recommendations.

Results: We assessed 35 HT recipients with CMV mismatch (median age of 48.8 ± 13.8 years, 71% men). Median follow-up was 5.5 years [1.9-7.4]. Median duration of CMV prophylaxis was 3.7 (±2.1) months post-HT. CMV infection occurred in 74% of patients (96% within the first 6 months after ending prophylaxis) and CMV disease in 26%. Half of them required hospital admission. One third had concomitant infections by other microorganisms. There were no significant differences in the duration of prophylaxis between patients with and without CMV infection. Survival on follow-up was 77%. 2 patients died during CMV infection due to other infection.

Conclusions: CMV infection rate in D+/R- HT receptors remains high even after the prophylactic period recommended by current guidelines. A better knowledge of CMV-transmitted infection, coupled with the pursuit of a suitable equilibrium between the prevention of infection and rejection, have the potential to enhance the outcomes of this high-risk population through tailored protocols.