The authors declare that financial support was received for the research and/or publication of this article. This work was supported by the Instituto de Salud Carlos III (Grant number PI19/01610), co-founded by the Spanish Cardiology Society (Grant number 19PSJ017) and by the Spanish Platform for (Grant number 19PSJ017) and by the Spanish Platform for Clinical Research and Clinical Trials, (Spanish Clinical Research Network), financed by the ISCIII-General Subdirectorate of Evaluation and Promotion of Research, through project PT17/0017/0010 and PT20/00008 integrated into the I+D+I 2013–2016 State Plan and co-financed by the European Regional Development Fund (FEDER). We thank CERCA Programme/Generalitat de Catalunya for institutional support

Catalá, Pablo

Comín Colet, Josep

Couto-Mallón, David

Donadeu, Laura

Donoso, Víctor

Díez-López, Carles

Fuente Galán, Luis de la

García-Cosío, María Dolores

García-Romero, Elena

González Vílchez, Francisco Jesús

Grande Trillo, Antonio

Gómez Molina, Miríam

Hernández-Pérez, Francisco José

Herrador, Lorena

Ibáñez,  Silvia

Kervella, Delphine

López López, Laura

Ortiz-Bautista, Carlos

Rosenfeld, Laia

Sabé, Nuria

Transplant International

English

UCrea

Protocol for the ELISPOT-TC Trial: ARandomized Controlled StudyEvaluating CMV-Specific CellularImmune Monitoring in HeartTransplant RecipientsElena García-Romero1,2,3,4*, Carles Díez-López1,2,3,4, Delphine Kervella5, Víctor Donoso6,María Dolores García-Cosío3,7, Carlos Ortiz-Bautista3,8, Francisco José Hernández-Pérez9,David Couto-Mallón3,10, Francisco González-Vílchez11, Luis De la Fuente-Galán3,12,Laura López-López13, Antonio Grande-Trillo14, Miríam Gómez-Molina15, Pablo Catalá12,Lorena Herrador1,2,3,4, Laia Rosenfeld1,2, Silvia Ibáñez1,2, Laura Donadeu5, Nuria Sabé16,Josep Comín-Colet 1,2,3,4, Oriol Bestard5,17 and José González-Costello1,2,3,41Cardiology Department, Bellvitge University Hospital, Barcelona, Spain, 2Bio Heart Cardiovascular Diseases Research Group,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain, 3Ciber Cardiovascular group (CIBER-CV), Instituto SaludCarlos III, Madrid, Spain, 4Universitat de Barcelona, Barcelona, Spain, 5Experimental Nephrology Laboratory, Vall d’HebronResearch Institute, (VHIR), Barcelona, Spain, 6Cardiology Department, Hospital Universitari i Politecnic La Fe, Valencia, Spain,7Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain, 8Cardiology Department, Hospital GeneralUniversitario Gregorio Maranon, Madrid, Spain, 9Cardiology Department, Hospital Universitario Puerta de Hierro Majadahonda,Majadahonda, Spain, 10Cardiology Department, Complexo Hospitalario Universitario A Coruna, A Coruña, Spain, 11CardiologyDepartment, Hospital Universitario Marques de Valdecilla, Santander, Spain, 12Cardiology Department, Hospital ClinicoUniversitario de Valladolid, Valladolid, Spain, 13Cardiology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain,14Cardiology Department, Hospital Universitario Virgen del Rocio, Seville, Spain, 15Cardiology Department, Hospital ClínicoUniversitario Virgen de la Arrixaca, Murcia, Spain, 16Infectious Diseases Department, Bellvitge University Hospital, Barcelona,Spain, 17Nephrology Department, Hospital Universitari Vall d’Hebron, Barcelona, SpainKeywords: cytomegalovirus (CMV), cellular immune response, heart transplantation, ELISpot, enzyme-linkedimmunosorbent spotDear Editors,Human cytomegalovirus (CMV) is the most frequent opportunistic infection in the early monthsafter heart transplantation with reported DNAemia in up to 40%–50% of high risk recipients andCMV disease in 10%–15% within the first year post-transplantation. CMV continues to exert a majornegative impact, contributing to acute rejection, opportunistic infections, coronary allograftvasculopathy, graft dysfunction and increased healthcare costs [1].Post-transplant risk stratification is based on donor–recipient serostatus (D+/R–as high risk,R+ as intermediate, and D–/R–as low); paradoxically CMV transmission and infection may stilloccur even in settings where immunity or prophylaxis should confer protection, reflectingorgan-specific variability in transmission risk and indicating that serology alone does notreliably reflect protective immunity, thereby highlighting the need for additional immunebiomarkers [2].Memory/effector T cells help control CMV through responses to IE-1 and pp65 antigens and theIFN-γ ELISpot assay enables the detection of CMV-reactive T cells and prediction of infection risk[3]. CMV-specific cellular immunity (CMI) can identify higher-risk kidney transplant recipients whoare more likely to develop CMV infection, while preserved CMV-CMI responses confer protectionagainst post-transplant replication and disease [4, 5]. Recent multicenter trials have furthersupported the role of immunoguided prophylaxis in solid-organ transplantation. In kidney andliver transplant recipients, immune monitoring based on CMV-specific T-cell responses safely*CorrespondenceElena García-Romero,e.garcia.r@bellvitgehospital.catReceived: 10 September 2025Revised: 31 October 2025Accepted: 13 November 2025Published: 27 November 2025Citation:García-Romero E, Díez-López C,Kervella D, Donoso V,García-Cosío MD, Ortiz-Bautista C,Hernández-Pérez FJ, Couto-Mallón D,González-Vílchez F,De la Fuente-Galán L, López-López L,Grande-Trillo A, Gómez-Molina M,Catalá P, Herrador L, Rosenfeld L,Ibáñez S, Donadeu L, Sabé N,Comín-Colet J, Bestard O andGonzález-Costello J (2025) Protocolfor the ELISPOT-TC Trial: ARandomized Controlled StudyEvaluating CMV-Specific CellularImmune Monitoring in HeartTransplant Recipients.Transpl. Int. 38:15565.doi: 10.3389/ti.2025.15565Transplant International | Published by Frontiers November 2025 | Volume 38 | Article 155651LETTER TO THE EDITORpublished: 27 November 2025doi: 10.3389/ti.2025.15565reduced antiviral exposure without increasing infection rates [6],whereas in lung transplantation, CMV-CMI–guided prophylaxisproved non-inferior to standard strategies while minimizingantiviral toxicity and adverse events [7].However, most studies assessing CMV-specific cellularimmunity have been conducted in kidney transplantation, andtheir findings may not be fully extrapolable to heart transplantrecipients, who face higher perioperative morbidity andmortality [5].Current Spanish and international guidelines for hearttransplantation provide only low-level evidence, and CMV-CMI monitoring is still recommended based solely on expertopinion, particularly in seropositive (R+) recipients [8, 9].Preventive strategies currently rely on universal prophylaxiswith valgancicloviror PCR-guided preemptive therapy. Whileeffective, both have limitations such as toxicity, late-onsetinfections, and viral resistance [8, 10].The ELISPOT-TC trial will address this gap by evaluatingwhether prophylaxis guided by CMV-specific CMI, assessed byIFN-γ ELISpot (T-SPOT.CMV), is non-inferior to universalvalganciclovir prophylaxis in seropositive heart transplantrecipients.It will be a phase IV, multicenter, open-label, randomized (2:1), non-inferiority clinical trial conducted across 11 Spanishtransplant centers. A total of 188 adult CMV-seropositiverecipients will be enrolled (125 experimental, 63 control) asshown in Figure 1.Patients will be randomly assigned by a centralized computersystem to either:- Group 1: CMI-guided prevention based on T-SPOT.CMV results, or- Group 2: Standard universal valganciclovir prophylaxisfor 3 months.FIGURE 1 | Flowchart of the trial.Transplant International | Published by Frontiers November 2025 | Volume 38 | Article 155652García-Romero et al. ELISPOT-TC CMV Monitoring TrialRandomized will be centralized and stratified by center. Theassigned preventive strategy will not be masked to investigators orparticipants.Eligible participants will be adult (≥18 years) CMV-seropositive recipients able to provide informed consent.All patients will undergo T-SPOT. CMV testing at day10 and at month 3 post-transplant,Viral load monitoringby quantitative nucleic acid testing (QNAT) will beperformed throughout follow-up according to astandardized schedule.In the experimental arm, T-SPOT. CMV testing at day10 post-transplant will classify patients as high or low risk,guiding either initiation of antiviral prophylaxis in thosewithout CMV-specific cellular immunity (high-risk) or a pre-emptive strategy in those with preserved immunity (low-risk).Patients will be followed for 48 weeks with scheduled visits tomonitor outcomes.The primary endpoint will be the cumulative incidence ofCMV infection at 1 year. Secondary endpoints will include theclassification of CMV infection into clinically significant andno-clinically significant categories (according to standardized,consensus-based viral load thresholds uniformly appliedacross centers and the presence of CMV-related symptomsor disease) as well as CMV disease, graft rejection,opportunistic infections, hematological adverse events,mortality, and cost-effectiveness.Analysis is planned both per-protocol and by intention-to-treat. Comparisons between groups will use standard tests forcontinuous and categorical variables, Cox proportionalhazards models for time-to-event analyses, and Kaplan-Meier survival curves. Non-inferiority will be assessed witha 10% margin. The trial will comply with the Declaration ofHelsinki and Spanish legislation and has received approvalfrom the national regulatory authority and local ethicscommittees. It has been registered at ClinicalTrials.gov(NCT04278547).This study will represent the first randomized multicentertrial in heart transplantation to use a validated andcommercially available IFN-γ ELISpot assay(T-SPOT.CMV) for guiding CMV prevention. As arandomized clinical trial, the study design will ensurestrong internal validity and methodological robustness,while stratification by center will enhance thegeneralizability of the results across diverse clinicalsettings. By prospectively integrating immunologicalmonitoring into a clinical decision algorithm, this trialtakes an essential step toward individualized prevention.The trial will not only examines efficacy and safety but will alsoaddress the economic impact, including both direct antiviral costsand indirect healthcare-related costs.Universal valganciclovir prophylaxis is effective but costlyand associated with frequent adverse events such as leukopeniaand neutropenia. A CMI-guided approach has the potential toreduce unnecessary drug exposure, minimize toxicity, andlower costs while maintaining protection. This aligns withthe broader movement toward precision medicine intransplantation [8, 9].Certain limitations should be acknowledged: variabilityamong participating laboratories may influence CMVDNAemia quantification despite standardized procedures;the exact proportion of patients who will ultimatelyreceive valganciclovir prophylaxis versus preemptivetherapy cannot be determined in advance; and the 48-weekfollow-up period will be insufficient to fully assess indirectCMV effects such as cardiac allograft vasculopathy, whichhas traditionally been one of the main arguments supportinguniversal prophylaxis.Despite these challenges, the ELISPOT-TC trial could supporta paradigm shift in CMV prevention. Instead of exposing allpatients to antiviral prophylaxis, immune monitoring could allowfor targeted use of therapy, reducing adverse events andimproving cost-effectiveness. The ELISPOT-TC trial thusrepresents a landmark step toward personalized preventionstrategies in transplantation [9].Detailed methods, inclusion criteria, statistical analyses, andfull CONSORT checklist will be provided in theSupplementary Material.Sincerely,DATA AVAILABILITY STATEMENTThe raw data supporting the conclusions of this article will bemade available by the authors, without undue reservation.ETHICS STATEMENTThe studies involving humans were approved by BellvitgeUniversity Hospital Ethics Committee, Barcelona, Spain.The studies were conducted in accordance with the locallegislation and institutional requirements. The participantsprovided their written informed consent to participate inthis study.AUTHOR CONTRIBUTIONSConceptualization/Design: EG-R, CD-L, DK, VD, MG-C, CO-B,FH-P, DC-M, FG-V, LF-G, LL-L, AG-T, MG-M, PC, LH, LR, SI,NS, JC-C, OB, and JG-C. Methodology/Investigation: All authors.Writing –Original Draft and Review: EG-R, CD-L, DK, VD,MG-C, CO-B, FH-P, DC-M, FG-V, LF-G, LL-L, AG-T, MG-M, PC,LH, NS, JC-C, OB, and JG-C. Resources/Analytic Tools: DK, LD,and OB. All authors contributed to the article and approved thesubmitted version.FUNDINGThe authors declare that financial support was received for theresearch and/or publication of this article. This work wassupported by the Instituto de Salud Carlos III (Grant numberPI19/01610), co-founded by the Spanish Cardiology SocietyTransplant International | Published by Frontiers November 2025 | Volume 38 | Article 155653García-Romero et al. ELISPOT-TC CMV Monitoring Trial(Grant number 19PSJ017) and by the Spanish Platform forClinical Research and Clinical Trials, (Spanish ClinicalResearch Network), financed by the ISCIII-GeneralSubdirectorate of Evaluation and Promotion of Research,through project PT17/0017/0010 and PT20/00008 integratedinto the I+D+I 2013–2016 State Plan and co-financed by theEuropean Regional Development Fund (FEDER). We thankCERCA Programme/Generalitat de Catalunya forinstitutional support.CONFLICT OF INTERESTThe authors declare that the research was conductedin the absence of any commercial or financial relationshipsthat could be construed as a potential conflict of interest.GENERATIVE AI STATEMENTThe authors declare that no Generative AI was used in thecreation of this manuscript.Any alternative text (alt text) provided alongside figures in thisarticle has been generated by Frontiers with the support ofartificial intelligence and reasonable efforts have been made toensure accuracy, including review by the authors whereverpossible. If you identify any issues, please contact us.SUPPLEMENTARY MATERIALThe SupplementaryMaterial for this article can be found online at:https://www.frontierspartnerships.org/articles/10.3389/ti.2025.15565/full#supplementary-materialREFERENCES1. Kotton CN, Kamar N. New Insights on CMV Management in Solid OrganTransplant Patients: Prevention, Treatment, and Management of Resistant/Refractory Disease. Infect Dis Ther (2023) 12(2):333–42. doi:10.1007/s40121-022-00746-12. Hernandez C, Mabilangan C, Burton C, Doucette K, Preiksaitis J.Cytomegalovirus Transmission in Mismatched Solid Organ TransplantRecipients: Are Factors Other than Antiviral Prophylaxis at Play? Am JTranspl (2021) 21(12):3958–70. doi:10.1111/ajt.167343. Lúcia MCE, Melilli E, Cruzado JM, Luque S, Llaudó I PreformedFrequencies of Cytomegalovirus (CMV)-Specific Memory T and B CellsIdentify Protected CMV-Sensitized Individuals Among SeronegativeKidney Transplant Recipients. Clin Infect Dis (2014) 59(11):1622–30.doi:10.1093/cid/ciu6784. Bestard O, Lucia M, Crespo E, Cruzado JM, Pérez D, Melilli E, et al.Pretransplant Immediately Early-1-Specific T Cell Responses ProvideProtection for CMV Infection After Kidney Transplantation. Am J Transpl(2013) 13(7):1793–805. doi:10.1111/ajt.122565. Jarque M, Crespo E, Melilli E, Gutiérrez A, Moreso F, Guirado L, et al.Cellular Immunity to Predict the Risk of Cytomegalovirus Infection inKidney Transplantation: A Prospective, Interventional, MulticenterClinical Trial. Clin Infect Dis (2020) 71(5):2375–85. doi:10.1093/cid/ciz12096. Manuel O, Laager M, Hirzel C, Neofytos D, Walti LN, Hoenger G, et al.Immune Monitoring–Guided Versus Fixed Duration of Antiviral ProphylaxisAgainst Cytomegalovirus in Solid-Organ Transplant Recipients: AMulticenter, Randomized Clinical Trial. Clin Infect Dis (2024) 78(2):312–23. doi:10.1093/cid/ciad5757. Páez-Vega A, Vaquero-Barrios JM, Ruiz-Arabi E, Iturbe-Fernández D, AlonsoR, Ussetti-Gil P, et al. Safety and Efficacy of Immunoguided Prophylaxis forCytomegalovirus Disease in Low-Risk Lung Transplant Recipients in Spain: AMulticentre, Open-Label, Randomised, Phase 3, Noninferiority Trial. LancetReg Health Eur (2025) 52:101268. doi:10.1016/j.lanepe.2025.1012688. Ruiz-Arabi E, Torre-Cisneros J, Aguilera V, Alonso R, Berenguer M,Bestard O, et al. Management of Cytomegalovirus in Adult Solid OrganTransplant Patients: GESITRA-IC-SEIMC, CIBERINFEC, and SETRecommendations Update. Transpl Rev (2024) 38(4):100875. doi:10.1016/j.trre.2024.1008759. Kotton CN, Kumar D, Manuel O, Chou S, Hayden RT, Danziger-Isakov L,et al. The Fourth International Consensus Guidelines on the Management ofCytomegalovirus in Solid Organ Transplantation. Transplantation (2025)109(7):1066–110. doi:10.1097/TP.000000000000537410. Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S, et al.The International Society of Heart and Lung Transplantation Guidelines forthe Care of Heart Transplant Recipients. Task Force 3: Long-Term Care ofHeart Transplant Recipients. J Heart Lung Transpl (2010) 29(8):914–56.doi:10.1016/j.healun.2010.05.034Copyright © 2025 García-Romero, Díez-López, Kervella, Donoso, García-Cosío,Ortiz-Bautista, Hernández-Pérez, Couto-Mallón, González-Vílchez, De la Fuente-Galán, López-López, Grande-Trillo, Gómez-Molina, Catalá, Herrador, Rosenfeld,Ibáñez, Donadeu, Sabé, Comín-Colet, Bestard and González-Costello. This is anopen-access article distributed under the terms of the Creative Commons AttributionLicense (CC BY). The use, distribution or reproduction in other forums is permitted,provided the original author(s) and the copyright owner(s) are credited and that theoriginal publication in this journal is cited, in accordance with accepted academicpractice. No use, distribution or reproduction is permitted which does not complywith these terms.Transplant International | Published by Frontiers November 2025 | Volume 38 | Article 155654García-Romero et al. ELISPOT-TC CMV Monitoring Trial

Protocol for the ELISPOT-TC trial: a randomized controlled study evaluating CMV-Specific cellular immune monitoring in heart transplant recipients

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Protocol for the ELISPOT-TC trial: a randomized controlled study evaluating CMV-Specific cellular immune monitoring in heart transplant recipients

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