*Purpose: The diagnosis of rejection after heart transplantation (HTx) is usually based on the surveillance endomyocardial biopsies (EMB). These protocol biopsies are performed at scheduled times following HTx in asymptomatic patients. Pathology-read biopsies appear to have a relatively high discordant rate. In the CARGO II trial, it was found that concordance for moderate rejection was only 28%. It is probable that some of these patients int he CARGO II trial may not have had true rejection and were treated unnecessarily. Treatment with augmentation of corticosteroids (IV or PO) is not benign. We sought to identify the infectious risk of augmentation of corticosteroids in asymptomatic patients in the first-year post-transplant.

*Methods: Between 2010 and 2017, we assessed 73 HTx patients with documented first-year pathology-read rejection (AMR, ACR) on surveillance EMB. First-year infectious complications requiring antibiotics (IV or PO) were recorded. Patients with no rejection episodes were used as a control (n=681).

*Results: Asymptomatic patients who were treated for rejection in protocol biopsies had significantly lower 1-year freedom from infection compared to the control population (see table). The type of infections included thrush, UTIs, pneumonia, etc. However, survival was similar between both groups.

*Conclusions: Augmentation of corticosteroids to treat rejection in asymptomatic patients undergoing surveillance EMBs is not benign and results in increased morbidity with infectious complications. With known discordance among pathology-read rejection on biopsies, more stringent and valid means to detect true rejection are needed to prevent unnecessary treatment.

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