*Purpose: The factors that lead to an increase in significant early rejection (stage 2R or greater) along with the preferred induction immunosuppression strategy in orthotopic heart transplant patients (OHT) remain unclear. Currently, there are two induction strategies used at our institution: basiliximab and Thymoglobulin compared to standard steroid-based immunosuppression regimen. The purpose of this project is to discover factors that predispose patients to progression to significant early rejection and to evaluate if changes to induction strategies are needed to improve cardiac transplantation outcomes.

*Methods: Between 2016-2019, there have been 60 histologically apparent early rejection patients at our institution: 25 patients with significant rejection and 35 with insignificant rejection (stage 1R or less). The induction regimen was documented for all 60 patients. The proportion of patients with early rejection on a certain immunosuppression strategy that progressed to significant rejection was calculated. Additionally, the odds ratio for certain identified risk factors were calculated to determine if they predisposed patient’s to higher rates of significant rejection.

*Results: Of the total patients who had rejection with basiliximab (n= 25), 44.0% of patients progressed to significant rejection. 45.5% of patients with rejection on Thymoglobulin (n=22) progressed to significant rejection. 30.8% of patients with rejection on methylprednisolone (n= 13) progressed to significant rejection. There was no statistical difference in progression to significant rejection when comparing basiliximab to Thymoglobulin (p= 0.42), basiliximab to methylprednisolone (p= 0.18) or Thymoglobulin to methylprednisolone (p = 0.24). In this study, patients under 40 years of age who underwent OHT (Odds Ratio [OR] 4.25), patients with left ventricular assist device (LVAD) prior to OHT (OR 1.95), and donor transplant ischemic time over 180 minutes (OR 1.18) predisposed patients to increased progression to significant rejection.

*Conclusions: This study reveals that there is no statistical difference in significant rejection outcomes between induction therapies with basiliximab and Thymoglobulin when compared to standard steroid based immunosuppression. Certain factors seem to increase the rates of significant early rejection in patients: 40 years of age or under at the time of transplant, having a LVAD prior to OHT, and time to ischemia in donor transplant over 180 minutes.

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