Introduction: Calcineurin inhibitors (CNIs) are nephrotoxic and have broad pharmacological interactions, which may be a problem in the treatment of transplant patients who use them. Belatacept is a non-nephrotoxic immunosuppressant whose function is the selective blockade of co-stimulation without demonstrated interaction with other drugs. Currently, scientific evidence supports the use of Belatacept in kidney transplants, however in heart transplant recipients there is still not enough evidence for its indication.

Objectives: To present four patients with orthotopic cardiac transplantation (OCT) who received Belatacept as primary immunosuppression in CNI-free regimen, one of them for previous renal failure and three for neurological pathology.

Clinical Cases: A 72-year-old male with necrotic ischemic cardiomyopathy was transplanted in September 2014, with a glomerular filtration rate (GFR) of 45 ml/min (MDRD-4). A 63-year-old man with chagasic cardiomyopathy, who received an OCT in June 2015. He had seizures and previous stroke, and was being treated with phenytoin. A 51-year-old man with necrotic ischemic cardiomyopathy, who received an OCT in October 2018. With cardiac arrest recovered with transient cerebral ischemia and mild renal failure in post transplantation. A 61-year-old male with chagasic cardiomyopathy, who was transplanted in July 2021 with PRES Syndrome post transplant. Because of these issues, the team decided to use Belatacept after obtaining informed consent. All received: Thymoglobulin 1.5 mg/kg/day for 5 days, 3 pulses of methylprednisolone, mycophenolate mofetil 2 g/day from day two and steroids were reduced as scheduled. Belatacept scheme: 10 mg/kg per day 7, 14, 28, 56 and 84 post transplant. From day 112 until now they have received Belatacept at a dose of 5 mg/kg every 28 days.

Conclusion: Tolerability to Belatacept was acceptable and patients did not develop acute episodes of graft rejection. Significant improvement in GFR and management of seizures was observed. However, clinical trials are insufficient to evaluate the efficacy and safety of Belatacept  in patients with heart transplantation.