Should heart-lung transplant donors and recipients be matched according to cytomegalovirus serologic status?

Cytomegalovirus (CMV) infection is a major cause of morbidity and mortality after heart-lung transplantation. Primary CMV infections in previously seronegative recipients are more severe than reactivated or reinfections in seropositive patients, and this has led to a policy of obligatory donor-recipient CMV matching in several centers performing heart-lung transplantation. Of our 13 heart-lung transplants, three were done in CMV-seronegative patients who received CMV-positive grafts. The first patient did not seroconvert and exhibited no evidence of CMV infection despite close follow-up extending to almost 2 years. In the second patient, who required augmented immunosuppression because of recurrent lung rejection early postoperatively, fulminating CMV pneumonitis developed, which was ultimately controlled with ganciclovir and high-dose CMV immune globulin. As an outpatient, she is currently receiving ganciclovir maintenance therapy. The third patient, who received high-dose CMV immune globulin prophylaxis, had CMV isolated from her bronchoalveolar lavage fluid, as well as from urine, but remains clinically well 5 months after receiving her transplant. We conclude that the matching of donors and recipients for CMV serologic status is desirable, but not essential, before heart-lung transplantation. CMV immune globulin prophylaxis may be effective in preventing clinical CMV disease in patients receiving a CMV-mismatched graft, and severe CMV pneumonitis may be effectively treated by a combination of ganciclovir and high-dose CMV immune globulin therapy.