*Purpose: Cardiac allograft vasculopathy (CAV) is impacted by acute rejection and ultimately limits long-term survival of orthotopic heart transplant (OHT) recipients, thus there is interest in assessing the effect of alemtuzumab induction on the incidence of CAV.

*Methods: This single-center, retrospective analysis included OHT recipients from 2010-2018 who received either alemtuzumab or no induction therapy. Maintenance immunosuppression consisted of tacrolimus, mycophenolate mofetil (MMF), and steroid tapers. The primary endpoint was freedom from International Society of Heart and Lung Transplantation (ISHLT) CAV1. Secondary endpoints included freedom from biopsy-proven acute rejection (BPAR) ≥ 1R or ≥ pAMR1 and cytomegalovirus (CMV) viremia. Cox proportional hazards models were used for primary and secondary outcomes. Event curves were generated using the Kaplan-Meier method.

*Results: Of 80 patients included, 47 received no induction and 33 received alemtuzumab. Baseline characteristics were similar between groups, aside from more chronic kidney disease in the alemtuzumab group. The intensity of maintenance immunosuppression was generally lower in the alemtuzumab group. Few patients were converted to sirolimus (30% for no induction vs. 36.4% for alemtuzumab, p=0.55) and conversion was typically delayed (644 days for no induction vs. 574.5 days for alemtuzumab, p=0.79). Calcium channel blocker, statin, and aspirin use was comparable; however, hemoglobin A1c, total cholesterol, and low-density lipoprotein were significantly higher in recipients receiving alemtuzumab. Freedom from ISHLT CAV1 was similar between the alemtuzumab and no induction groups (HR, 0.83; 95% CI, 0.42-1.67; p=0.62). Median time to CAV1 was longer for alemtuzumab; this difference was not significant [741 days (363-967.5) vs. 365.5 days (120.8-842.3), p=0.20]. Alemtuzumab significantly improved freedom from BPAR (HR, 0.28; 95% CI, 0.15-0.54; p=0.0006), driven by lower acute cellular rejection (HR, 0.39; 95% CI, 0.14-0.62; p=0.004). Freedom from CMV viremia was similar between groups (HR, 1.39; 95% CI, 0.49-3.94; p=0.52).

*Conclusions: The present study suggests that induction with alemtuzumab results in lower BPAR compared to OHT recipients receiving no induction; however, this did not result in lower CAV1. Metabolic factors, donor-specific antibody, maintenance immunosuppression, and donor anatomy are additional factors that should be considered.

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