Cytomegalovirus infection in heart transplant recipients: Epidemiology, risk factors, and long-term outcomes from a major transplant center in the United States

Abstract

Background: Despite the use of antiviral prophylaxis, cytomegalovirus (CMV) remains a common opportunistic infection following heart transplantation. This study analyzes the rates, risk factors, and outcomes of CMV among heart transplant recipients. Methods: A retrospective cohort study was conducted of adults who underwent heart transplantation between January 1, 2011, and March 31, 2019. The primary outcome was clinically significant CMV infection (csCMVi), defined as CMV disease or asymptomatic infection requiring pre-emptive therapy. The secondary outcome was all-cause mortality. Patients received valganciclovir prophylaxis up to 6 months, depending on CMV donor/recipient serostatus. Kaplan-Meier curve and multivariable Cox regression were used for outcome analysis. Results: Among 553 heart transplant recipients, 101 (18.3%) experienced csCMVi, including 35 (6.3%) with CMV disease. csCMVi was uncommon during prophylaxis. In multivariable analysis, CMV D+/R– status hazard ratio (HR 12.88, 95% CI 6.76-24.56; p < 0.001) and lower absolute lymphocyte counts in seropositive recipients (HR 1.48, 95% CI 1.23-1.79; p < 0.001), but not CMV D+/R– patients (HR 1.18, 95% CI 0.94-1.47; p = 0.162), were significantly associated with csCMVi. Sixty patients died during follow-up, and csCMVi was associated with increased mortality (HR 2.84, 95% CI 1.62-4.98; p < 0.001). Conclusions: In this large cohort of heart transplant recipients, csCMVi was linked to higher mortality. CMV D+/R– serostatus was associated with an increased risk of csCMVi, with lower absolute lymphocyte counts increasing risk only in CMV seropositive recipients. Strategies for optimizing CMV prevention in serodiscordant heart recipients are warranted.

Keywords

• cytomegalovirus
• heart transplantation
• opportunistic infection
• antiviral