*Purpose: Using HCV viremic grafts for heart transplantation (HT) improves donor supply and shortens wait times. However, treatment strategies are variable post-transplant. This study aims to evaluate outcomes from multiple treatment regimens at two centers in the United States.

*Methods: This is a retrospective review of the outcomes of HT recipients of HCV viremic grafts from 2019 – 2021.

*Results: At Center 1, 13 patients underwent HT from HCV positive donors. These were 12 men, 1 woman, 10 Caucasians, 2 African-Americans and 1 Hispanic. Median recipient age was 59 years. 4 patients were treated preemptively per a study protocol with glecaprevir/pibrentasvir (G/P) and ezetimibe, 1 dose prior to surgery followed by 7 days of therapy. 9 patients were treated reactively starting at a median of 4 days after transplant with baseline median peak viral load of 5,690 IU/mL. 7 patients received G/P for 12 weeks, and 2 patients received G/P for 8 weeks. All patients achieved sustained virological response (SVR). Median time to HT was 1.7 months compared with 3.7 months for the region and 6.2 months for the United States. 8 patients had mild acute cellular rejection in their post-transplant course to date, 1 had antibody-mediated rejection and 1 had CMV viremia. Average ejection fraction (EF) on echocardiogram was 61.5% on most recent follow up ranging from 4 months to 28 months post-transplant. At Center 2, 11 patients underwent HT from HCV positive donors. There were 8 men, 3 women, 9 Caucasians and 2 African-Americans. Median age was 64 years old. 1 patient did not become viremic post-transplant. All viremic patients were treated reactively with sofosbuvir/velpatasvir (S/V) for 12 weeks (6 patients), G/P for 8 weeks (1 patient), or G/P for 12 weeks (4 patients) per insurance preference. Treatment started at a median of 29.5 days after transplant with baseline median peak viral load of 8,210,000 IU/mL. All patients achieved SVR. Median time to HT was 2.1 months compared with 7.3 months for the region. Each patient had 1 or more episodes of mild acute rejection on biopsy with 1 patient having moderate acute rejection to date. 1 patient had CMV viremia. Average EF on echocardiogram was 61.8% on most recent follow up ranging from 9 months to 27 months post-transplant. 1 patient died of non-transplant related causes.

*Conclusions: Despite various treatment regimens and strategies, all patients were cured of hepatitis C, had reduced time on the waiting list and had similar post-transplant cardiac function.

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