*Purpose: To assess the safety and efficacy of rATG induction in heart transplant recipients at high risk for rejection.

*Methods: This was a single-center, retrospective study comparing outcomes between patients receiving rATG induction vs. no induction. We included adults who underwent heart transplantation consecutively from January 2012 to September 2017. All patients included were considered high immunologic risk defined as one of the following: prior desensitization, history of previous transplantation, calculated panel reactive antibodies (cPRA) > 10%, peak cPRA > 50% within the year prior to transplant, presence of pre-transplant donor specific antibody (DSA), positive flow crossmatch, or any 3 of the following: cPRA 1-10%, black race, age < 40 years, female gender, or ≥ 4 human leukocyte antigen (HLA) mismatches. All patients followed the same protocol consisting of tacrolimus and mycophenolate throughout the study period. Prednisone doses were minimized in patients receiving rATG after 2014. The primary outcome assessed at 1 year was a composite of ISHLT ≥ 2R rejection, any treated rejection, development of cardiac allograft vasculopathy (CAV), or graft loss. Additionally, this study assessed rATG associated adverse effects and metabolic parameters to evaluate the impact of steroid minimization in the rATG group.

*Results: Twenty-one patients received rATG and 29 patients received no induction. The rATG group included more patients with cytomegalovirus (CMV) mismatch and cPRA > 25% at baseline (Table 1). There was no difference in the composite primary outcome between the rATG and no induction groups (Table 2). The rate of infusion reactions, serious infections and post-transplant lymphoproliferative disease were similar between groups (Table 2). As expected from protocol change in 2014, prednisone dose at month 1 was lower in the rATG group, but no difference existed at month 6 or 12 (Table 3). Incidence of new onset diabetes after transplant and changes in triglycerides were similar between groups (Table 2).

*Conclusions: In immunologically high-risk heart transplant recipients, rATG did not significantly reduce the composite primary outcome. However, rATG enabled a safe reduction in steroid dose early after transplant. Adequately powered studies are needed to further analyze the impact of induction in this patient population.

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