Similar Goals, Divergent Paths: Exploring Approaches to Hepatitis C Treatment Protocols in Heart Transplantation

Heart transplantation from hepatitis C-positive donors is on the rise, yet there exists divergence in approaches to managing recipients of these organs. Practices range from prophylactic treatment of recipients prior to transplantation to delayed treatment following the detection of viremia, with no established consensus on the optimal approach.

An online survey was conducted among the heart transplant centers in the United States and Canada from January 2023-February 2024. The survey gathered comprehensive information from the institutions regarding direct antiviral (DAA) therapies used, timing and duration of DAA, frequency of viral load testing, adverse effects, virological response, and immunosuppressive therapy modifications. The treatment pathways were categorized based on the timing of treatment initiation into prophylactic, preemptive or reactive approaches. Analysis was restricted to adult transplant programs in the U.S. that had an HCV transplant protocol and performed at least 1 HCV NAT-positive transplant. The Scientific Registry of Transplant Recipients database was queried for total heart transplants using hepatitis C virus nucleic acid testing (HCV NAT)-positive donors.

Of 122 heart transplant programs, 35 (28.7%) institutions responded; 689 heart transplants (49.1%) using HCV NAT-positive donors were captured across institutions. Among 30 U.S. institutions performing adult heart transplantation with HCV NAT-positive donor hearts, 5 (16.7%) used prophylactic, 9 (30%) preemptive and 16 (53.3%) reactive treatment pathways. Most employed pan-genotype DAA therapies for a median of 12 weeks. Significant heterogeneity existed in treatment and monitoring protocols.

Practice patterns for management of HCV NAT-positive donor hearts vary significantly. Establishing registries and randomized control trials for these patients is crucial for guiding future practices.