This was a retrospective, single-centre study of all patients undergoing first heart transplantation in Gothenburg, Sweden, between January 1988 and December 2000. During this period, 283 transplantations were performed in 278 patients. Of these, 34 patients died within 30 days of transplantation and were excluded from the analysis, as were 17 children < 14 years and one patient for whom the record from 1988 could not be found. In 226 patients, CMV infection, disease and potential risk factors were evaluated during the first 12 months after transplantation. Angiographic signs of CAV were recorded for 10 years or until death. Cardiovascular risk-factors were monitored according to protocol. Statins was given as universal therapy after 1996. Follow-up of all patients was complete through 31 December 2000. No patients were lost to follow-up.

The induction therapy during 1988–1993 consisted of cyclosporine A (CsA) and from 1994 of anti-thymocyte globulin (ATG; 2.5 mg/kg/day administered intravenously before surgery and for 3 to 5 days afterwards). Daclizumab or 100 mg of prednisone was given in the event of ATG allergy. Methylprednisolone was administered at 500 mg intravenously before surgery and 500 mg intra-operative and then at 125 mg every 8 hours for 3 doses during the whole study period. The maintenance immunosuppression therapy consisted of standard triple therapy. CsA (5 to 8 mg/kg/day) was used to maintain serum CsA levels within range 200–350 ng/ml during the first year and from 100 to 200 ng/ml thereafter. Azathioprine (AZA) was administered at 2 mg/kg/day, and prednisone at 0.2 mg/kg/day reduced to 0.1 mg/kg/day orally. Since 1995, Tacrolimus (TAC) was an alternative to CsA, given at 0.075 mg/kg to maintain serum tacrolimus levels within range 10–15 ng/ml and, since 1997, AZA was replaced by mycophenolate mofetil (MMF) (2–3 g/day).

CMV infection was detected by serology (seroconversion post-transplant), viral culture, qualitative polymerase chain reaction (PCR) for CMV DNA, histopathology and immunohistochemistry (IHC) with CMV-specific antibodies from endomyocardial biopsies (EMB) or tissue biopsies from other organs. Clinical symptoms of CMV disease were also documented for 12 months after transplantation.

CMV infection: CMV virus detected by viral culture or qualitative, PCR assay for CMV in any body fluid or tissue specimen. Seroconversion from CMV (seronegative to seropositive) was also regarded as CMV infection.

CMV infection was categorised as either asymptomatic CMV infection or CMV disease.

Asymptomatic CMV infection: Evidence of CMV infection but not fulfilling criteria for CMV disease.

CMV disease: Evidence of CMV infection with attributable symptoms in accordance with Ljungman et al. [16]. CMV disease was categorized as tissue-invasive disease or CMV syndrome with fever, leucopoenia and/or thrombocytopenia.

All patients during 1988 to 1991: No CMV prophylaxis was given. Patients were tested frequently. Seronegative patients received treatment with intravenous (i.v.) ganciclovir or foscavir for 14–21 days in the event of seroconversion or a positive viral culture for CMV.

High-risk group (D+/R−) during 1992 to 1997: Pre-emptive treatment was given, comprising monitoring with qualitative CMV PCR once weekly during the first three months post-transplantation. When CMV DNA was detected in serum, patients received treatment with i.v. ganciclovir for at least 10 days. During 1998–2000, universal prophylaxis was given with 1,000 mg of oral ganciclovir tid for 14 weeks.

Intermediate-risk group (R+) during 1992 to 2000: No prophylaxis was given. Qualitative CMV PCR was analyzed in serum when CMV disease was clinically suspected.

In D+/R−transplants, serological analyses were repeated once monthly for the first 4 months after HTx, then at 6, 9 and 12 months and thereafter annually and when infection was suspected during 1988 to 1998.

CMV disease was treated with 5 mg/kg of i.v. ganciclovir bid for 10–21 days. Asymptomatic CMV infection was treated in seronegative recipients. Ganciclovir dosing was adjusted for renal function. Patients who developed severe CMV pneumonitis (hypoxia) also received polyclonal immunoglobulin.

All available coronary angiographic studies performed in the study cohort between the first and tenth year of follow up, or until death or re-transplantation, were retrospectively re-analyzed visually. Where coronary angiography was not performed in patients who were alive during the study period it was due to medical contraindications or patient refusal. CAV-free survival was defined as the time to CAV of any grade observed visually by angiography. CAV was graded according to Costanzo et al. (none, mild, moderate or severe) [17]. The severity of CAV (none, mild, moderate, severe) was assessed throughout follow up. Donor-related coronary artery disease was defined as no stenosis = 0 or no significant stenosis = 1 from coronary angiographic studies performed before HTx.

Data on potential risk factors for CAV were collected retrospectively, including recipient and donor characteristics, cold ischemic time, cardiovascular risk factors (hypertension, diabetes mellitus, smoking status before transplantation and complications (acute rejection (AR) episodes).

Surveillance endomyocardial biopsies for AR were standardized for all patients and graded according to the 2005 ISHLT classification as 1R, 2R or 3R [18]. AR therapy consisted of 1,000 mg boluses of methylprednisolone for 3 consecutive days in cases of AR ≥ 2R. Severe cellular rejections were treated with 2.5 mg/kg/day of ATG for 3 days. Clinical relevant antibody-mediated rejection (AMR) was treated with plasmapheresis. The cumulative effect of acute cellular rejection was assessed by the total rejection score (TRS) [19] and defined as 0R = 0, 1R = 1, 2R = 2, 3R = 3. Severe TRS was defined as all AR ≥ 2R. The scores were normalized for the total number of biopsy specimens taken during the first 12 months after HTx (TRS or TRS ≥ 2R) in the individual patient.

This study was approved by the local Ethical Committee of Gothenburg (115–14) and by the medical director of the heart transplant department at the University Hospital, Gothenburg, Sweden. The data were recruited from the patients’ medical records and local registries according to standards by the Declaration of Helsinki.

Data were analyzed using SPSS version 20.0 (SPSS Inc, Chicago, IL, US). Continuous variables are presented as mean values ± standard deviations (SD) and categorical variables as percentages. The chi-square test was used to compare proportions and occurrences between groups. Confidence intervals (CI) were calculated using a normality approximation algorithm. Survival and CAV-free survival time was analyzed using the Kaplan–Meier procedure and statistical comparisons of survival distributions between different categories were made using the log rank test. Cox’s univariate and multivariate model was used to determine risk factors for events. Variables in the univariate model testing with a p value < 0.1 were included in the multivariate model. A p value < 0.05 was considered statistically significant.

In total, 226 patients who received a first HTx and had complete data regarding CMV infection during the first post-transplant year were included in the analysis. The baseline characteristics of recipients and donors are described in Table 1. The main causes of death were CAV (14 %), acute rejection (3 %) and infection (9 %). The mean follow-up for CAV disease was 8.9 years.Table 1

Patient characteristics (n = 226)

Diagnosis of CMV infection or disease were performed by seroconversion in 25 patients, qualitative CMV PCR in 49 patients, tissue biopsies with histopathology and IHC with CMV-specific antibodies in 19 patients, and viral culture in 16 patients. CMV retinitis was diagnosed in one patient by an ophthalmologist.

Of the 226 patients analyzed, 28 % (n = 64) developed CMV disease (tissue invasive, 11 % (n = 26) and 17 % (n = 38) developed CMV syndrome). Asymptomatic CMV infection was detected in 20 % of patients (n = 46).

In the 26 patients with tissue-invasive CMV disease, the following manifestations were recorded; myocarditis (n = 10), myocarditis + pneumonitis (n = 1), myocarditis + gastrointestinal disease (n = 1), gastrointestinal disease (n = 7), pneumonitis (n = 5), nephritis (n = 1) and retinitis (n = 1). The 26 cases of tissue-invasive CMV disease were proven in 85 % of the patients (n = 22) and possible in 15 % (n = 4).

The incidences of CMV disease and asymptomatic CMV infection according to the CMV serology status (donor positive (D+) or negative (D−) vs recipient positive (R+) or negative (R−)) are shown in Table 2. The onset of CMV disease in the high risk (D+/R−) serology group without CMV prophylaxis occurred significantly earlier (57 (22–178) days) after transplantation compared to the patients given oral ganciclovir for 14 weeks (103 (64–156) days) after transplantation (p = 0.008). There was no significant difference in the onset of CMV disease in the intermediate-risk serology groups (R+) without prophylaxis (45 (19–86) days) compared with targeted prophylaxis (51 (17–151) days) after transplantation (p = ns).Table 2

Morbidity in CMV disease and asymptomatic CMV infection related to CMV serostatus

The combined incidence of CMV disease or asymptomatic CMV infection was highest in the D+/R− group compared with the D+/R+, D−/R+ and D−/R− groups (p < 0.001) (Table 2). When the different eras of prophylaxis strategy were taken into account, there was no statistical significant difference in the incidence of CMV disease or asymptomatic infection compared to no CMV infection in the high risk (D+/R−) group (p = 0.08) (Table 3) or the intermediate-risk (R+) group (p = 0.25) (Table 4). In addition, across the total study group there was no statistical difference between different eras in terms of the incidence of CMV disease or asymptomatic CMV infection (p = 0.62) at 1 year after transplantation.Table 3

Incidence of CMV disease and asymptomatic CMV infection in D+/R− transplants according to era after HTx

There were no significant differences in the risk for CMV disease or asymptomatic CMV infection versus no CMV infection according to recipient age (p = 0.537), donor age (p = 0.072), TRS at 1 year post-transplant (p = 0.483) or TRS ≥ 2R score at 1 year (p = 0.259).

Survival was 7.0 years (95 % CI 6.0–7.9) for patients with CMV disease, 7.5 years (95 % CI 6.4–8.5) with asymptomatic CMV infection and 8.7 years (95 % CI 8.2–9.2) with no CMV infection. Survival at 10 years post-transplant (mean 9.9 years) was significantly higher for patients without CMV infection (69 %), compared with patients who had CMV disease (55 %; p = 0.018) or asymptomatic CMV infection (54 %; p = 0.053) (Fig. 1).Fig. 1

Survival—10 years of follow-up in 226 heart transplant recipients. Survival during a follow-up of 10 years was significantly higher for patients without CMV infection, n = 116 (69%), compared with patients with CMV disease, n = 64 (55%; p = 0.018), and asymptomatic CMV infection, n = 46 (54%; p = 0.053). (Patients were followed to re-transplantation (n = 5) or death) Kaplan–Meier survival curve, the mean follow-up was 9.9 years

A total of 1272 coronary angiographic studies performed in 204 patients between 1 and 10 years after HTx were re-analyzed. Twenty-two patients did not survive to the first coronary angiography. In the last coronary angiography performed, no CAV was found in 113 (50 %) patients, mild CAV in 40 (18 %) patients, moderate CAV in 41 (18 %) patients and severe CAV in 10 (4 %) patients. Sixty-four coronary angiographies were performed in donors before HTx. Thirty-one patients had CAV at the first year after HTx, of whom 6 had donor-related coronary artery disease and 8 had no lesions on angiography before HTx. The TRS at one year was 0.49 ± 0.30 and TRS ≥ 2R was 0.22 ± 0.20. Histologically suspected AMR was found in 26 patients, 5 of whom received plasmapheresis and 1 underwent re-transplantation due to graft loss.

CAV-free survival for the total study population was 5.7 years (95 % CI 5.21–6.24). CAV-free survival was significantly longer for patients without CMV infection 6.7 years (95 % CI 6.0–7.4) compared with patients with CMV disease 4.2 years (95 % CI 3.2–5.2) (p < 0.001) or asymptomatic CMV infection 5.4 years (95 % CI 4.3–6.4), (p = 0.013) (Fig. 2).Fig. 2

CAV-free survival—10 years of follow-up in 226 heart transplant recipients. CAV-free survival during a follow-up of 10 years was significantly higher for patients with no CMV infection (n =116) compared with patients with CMV disease (n = 64; p <0.001) and asymptomatic CMV infection (n = 46; p = 0.013). (Patients were followed to re-transplantation (n = 5) or death) Kaplan–Meier curve, the mean follow-up was 8.9 years