Heart Transplantation in Recipients With Hepatitis B Surface Antigen Positivity: A Single-Center Cohort Analysis

All articles of this category (opens in new window) Background: Heart transplantation (HTX) is the definitive therapy for end-stage heart failure. Hepatitis B virus (HBV) raises concern due to the risk of reactivation under lifelong immunosuppression. Guidelines recommend inclusion of HBV-positive recipients if antiviral prophylaxis and close monitoring are ensured, but clinical evidence in HTX remains limited. Methods: We retrospectively analyzed 374 adult HTX recipients (2010–2025) with known hepatitis B surface antigen (HBsAg) status. Patients were stratified into HBsAg-positive and HBsAg-negative groups. Perioperative support, early complications, infectious events, and virological follow-up were compared. HBV monitoring included serial HBsAg, HBV-DNA PCR (where available), and liver function tests during the first year and at routine follow-up. Results: Among 374 recipients, 4 patients (1.1%) were HBsAg-positive, while 370 (98.9%) tested negative. ECMO support after HTX was required in two of four HBsAg-positive patients (50%) and in 121 of 370 HBsAg-negative patients (32.7%). No major complications within 1 year were observed in HBsAg-positive patients, compared with 14 cases (3.8%) among HBsAg-negative recipients. Pretransplant infections were present in all HBsAg-positive patients (100%) and in 94.3% of the HBsAg-negative group. After transplantation, infections occurred in three of four HBsAg-positive patients (75%) vs. 148 of 370 HBsAg-negative patients (40.0%). During follow-up, two recipients cleared HBsAg, while two remained persistently HBsAg-positive without viral replication. Importantly, none demonstrated HBV-DNA positivity or clinical evidence of reactivation. Conclusion: Heart transplantation in HBsAg-positive recipients is feasible and was not associated with HBV reactivation under guideline-based monitoring. Half of these patients cleared HBsAg during follow-up, while the others remained persistently positive but clinically stable. This subgroup showed numerically higher rates of posttransplant infections and ECMO use compared with HBsAg-negative recipients. Although limited by a small sample size, our findings support the inclusion of HBV-positive recipients in transplant programs, provided systematic virological surveillance and antiviral prophylaxis are ensured. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany