Respiratory Reactivation of Herpes Simplex Virus-1 Following Cardiac Surgery in Immunocompetent Individuals

Abstract

Objective: Herpes simplex virus type 1 reactivation is common in immunocompromised patients. Its frequency and clinical significance as a cause of pneumonia in immunocompetent patients, particularly following cardiac surgery, remain poorly defined. This review synthesizes all the evidence on the frequency, pathophysiology, and clinical impact of herpes simplex virus reactivation in immunocompetent patients following cardiac surgery.

Design: Systematic review.

Setting: Studies conducted in cardiac surgery.

Participants: Immunocompetent adults with suspected or confirmed herpes simplex virus pneumonia after cardiac surgery.

Measurements and main results: Medical databases were searched from inception to June 4, 2025. Studies reporting immunocompetent adults with suspected and/or confirmed herpes simplex virus pneumonia post-cardiac surgery were included. Twenty studies (published in the period 1983-2025), including 112 patients with pneumonia and herpes simplex virus reactivation after cardiac surgery, were identified. Bronchoalveolar lavage was used as a diagnostic tool in 79% of cases. The use of antiviral treatment (predominantly acyclovir) was reported in 42 of 78 patients (53%). All-cause mortality was 14 of 30 patients (46%).

Conclusion: Herpes simplex virus reactivation after cardiac surgery is not frequently reported, but mortality approaches 50%. This underscores the need for heightened awareness and targeted testing in nonresponding pneumonias, potentially improving outcomes. Even if patients often die with the herpes simplex virus reactivation complicating other severe conditions, the frequency with which herpes simplex virus reactivation itself is the primary cause of death remains uncertain. Diagnosis relied mainly on polymerase chain reaction, and early antiviral treatment was frequently administered. Increased clinical awareness and further research are warranted to standardize diagnosis and optimize management.

Keywords: acyclovir; cardiac surgery; herpes simplex virus type 1; immunocompetent patients; pneumonia; postoperative complications.