A new era in transplantation: Overcoming COVID-19 challenges

• Among solid organ transplant recipients (SOTRs), lung and heart transplant recipients had the highest risk for severe COVID-19. • We are facing an endemic phase of SARS- CoV-2 infection with transplant activity resuming fully. • Current guidelines recommend excluding recipients who test positive for SARS-COV-2 at the time of transplantation. • The new epidemic phase, characterized by a population with enhanced immunity from natural infections and vaccinations, might need a reconsideration of these guidelines, as disease courses are often mild. Additionally, effective antiviral treatments and improved understanding of the infection allow safer management, even for immunosuppressed patients, utilizing therapies such as antiviral agents and immune modulators. Background: Among solid organ transplant recipients (SOTRs), lung and heart transplant recipients had the highest risk for severe COVID-19. Methods: We present two cases of two heart transplant recipients who underwent transplantation despite perioperative SARS-CoV-2 positivity. We reviewed the clinical records of the two patients. Both patients received a five-day course of Remdesivir (200 mg loading dose, followed by 100 mg daily). Immunosuppression regimens were adapted to reflect standard protocols but included tailored modifications. Thymoglobulin induction was administered at half the usual dose (0.75 mg/kg/day for 72 h), corticosteroids were initiated at a high dose and subsequently tapered to oral prednisone by the end of the first week, and cyclosporine was started on day 3 at 50% of the standard dosage. These adjustments aimed to balance the risk of rejection with the known lymphopenic effects of COVID-19. Results: The postoperative recovery was uneventful, with no complications related to the infection, either systemic or involving the transplanted organ. Conclusion: These cases highlight that transplant candidates with asymptomatic or mildly symptomatic SARS-CoV-2 may safely undergo urgent transplantation when managed with careful antiviral and immunosuppressive strategies. Decisions should be individualized, considering waitlist mortality, infection status, and organ availability. Additionally, these cases underscore the need for a comprehensive review of existing guidelines to inform evolving peri -transplant protocols. Conclusion: These cases highlight that transplant candidates with asymptomatic or mildly symptomatic SARS-CoV-2 may safely undergo urgent transplantation when managed with careful antiviral and immunosuppressive strategies. Decisions should be individualized, considering waitlist mortality, infection status, and organ availability. Additionally, these cases underscore the need for a comprehensive review of existing guidelines to inform evolving peri -transplant protocols.