A call for cytomegalovirus stewardship initiatives in cardiothoracic transplant

Despite the availability of potent antiviral therapy and increasingly long prophylaxis courses, cytomegalovirus (CMV) infection continues to negatively affect outcomes after cardiothoracic transplant (CT). CMV antiviral stewardship (AVS) represents an opportunity to implement organ-specific prophylaxis, treatment, and monitoring algorithms while optimizing care of the allograft and patient. Within the nuanced context of heart and lung transplant recipients, CMV prophylaxis, monitoring, and treatment strategies are reviewed for efficacy and safety. These insights highlight opportunities for CMV AVS programs to combine organ- and patient-specific data while implementing CMV guidelines, appropriately adopted to local context by local experts, with concurrent and retrospective evaluation for each patient and the transplant program. By applying concepts of CMV AVS currently practiced in abdominal transplant, CT programs can work to improve graft and patient outcomes related to CMV, including ongoing challenges such as atherosclerosis and impaired endothelial function in heart transplant recipients and chronic lung allograft dysfunction in lung transplant recipients. While implementation of CMV AVS is not without challenges, it also represents an opportunity for multidisciplinary teams to foster the development of CMV-specific cell-mediated immunity and improve long-term outcomes.