*Purpose: Invasive fungal infection (IFI) after heart transplantation is a feared complication associated with significant morbidity and mortality. Risk factors for invasive fungal infection after heart transplantation are not well defined and vary by time from transplantation. We sought to analyze a large cohort of patients undergoing heart transplantation, and review epidemiology of early (defined as less than 12 months after transplantation) and late onset of IFI in the current era.

*Methods: We conducted a retrospective cohort study of patients undergoing heart transplantation from January 2000 to March 2019. We identified baseline characteristics, transplant operation duration, need for re-operation, post transplantation renal replacement therapy, use of perioperative antifungal prophylaxis, and occurrence of fungal infection. We determined overall incidence of early and late IFI after transplantation and described the infections found.

*Results: We identified 315 patients undergoing heart transplantation during the specified timeframe. 222 (70.5%) were male with a median age of 53.4 years (IQR 45.3-60.9). 7 patients were undergoing a second transplantation. The most common indications for heart transplantation included 130 for non-ischemic cardiomyopathy and 97 for ischemic cardiomyopathy. 86 patients required a ventricular assist device prior to transplant.

We identified a total of 21 patients who developed early IFI, for an incidence of 6.7%. Most common causative organisms included 9 with Candida and 7 with Aspergillus. Late IFI occurred in 10 patients, and most common organism being Aspergillus.

Compared to those without early IFI, those who developed early IFI were noted to have higher rates of open chest postoperatively (33.3% vs 15.3%), renal replacement therapy (42.9% vs 8.8%), and ECMO requirement (14.3% vs 3.4%). Median duration of transplant operation was 432.0 min in those who developed early IFI, compared to 348.5 min in those who did not. Early IFI incidence in those transplanted between 2000 and 2009 was 1.8%, compared to 12.1% from 2010 to 2019.

*Conclusions: IFI incidence has increased in our patient population over the last decade, compared to the decade prior. We suspect this was driven by the increased medical complexity noted in the population, and re-evaluation of prevention of IFI in heart transplant recipients is needed.

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