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Purpose Hypertension after heart transplantation (HTx) is noted in a majority of HTx patients due to the side effects of calcineurin inhibitors (CNI). The use of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) are effective anti-hypertensive agents and may have longer term clinical benefits. We assessed our patients on ACEI/ARBs versus others in the first year post-HTx and followed them for 5-year outcomes. Methods Between 2010 and 2015, we assessed 101 HTx patients who were on ACEI/ARBs only in the first year for more than 6 months. Those patients were then followed for 5 years. Likewise, a group of patients who were placed on non-ACEI/ARBs blood pressure medications, such as calcium channel-blockers, beta blockers, and diuretics, in the first year for more than 6 months were the control group. Outcomes included 5-year survival, 5-year freedom from non-fatal major adverse cardiac event (NF-MACE: MI, new CHF, PCI, ICD implant, stroke), freedom from cardiac allograft vasculopathy (CAV: angiographic stenosis >30%), freedom from left ventricular dysfunction (left ventricular ejection fraction ≤40%) and freedom from left ventricular hypertrophy (LVH), defined as intraventricular septum or posterior wall ≥1.3cm. Results The patients treated with ACEI/ARBs in the first year post-HTx compared to those without had significantly lower 5-year survival but a trend for greater 5-year freedom from CAV. There was no significant difference between the two study groups in 5-year freedom from NF-MACE, left ventricular dysfunction and LVH (see table). Baseline demographics between groups were similar for recipient age, % female, pre-transplant diabetes and renal dysfunction (creatinine >1.5mg/dl) (data not shown). Conclusion The use of ACEI/ARBs in the first year post-HTx is associated with lower survival but other factors may be involved. A possible lower development of CAV from ACEI/ARBs may be a benefit to be explored.

Purpose Patients with severe heart failure who have undergone placement of a mechanical circulatory support (MCS) device do develop renal dysfunction. This renal dysfunction is not severe enough to necessitate the use of combined heart transplantation (HTx) and kidney transplantation. However, it has not been firmly established whether kidney dysfunction does add to increased morbidity or mortality after HTx in these device patients. Methods Between 2012 and 2019, we assessed 79 patients who have undergone MCS, either with total artificial heart (n=22) or left ventricular assist device (n=53). Baseline creatinine/glomerular filtration rate (GFR) was measured and patients were divided into GFR categories which include 30-39 mL/min, 40-49 mL/min, 50-59 mL/min, and greater than or equal to 60 mL/min. All patients underwent HTx alone. The need for temporary dialysis was recorded, as well as peak creatinine in the first 3 months after HTx and serum creatinine at 1 year compared to baseline. Further outcomes include subsequent 1-year survival, freedom from cardiac allograft vasculopathy (CAV, stenosis ≥30%), and freedom from non-fatal major adverse cardiac event (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke). Results There was no significant difference in 1-year survival, CAV, and NF-MACE or the need for temporary dialysis amongst all groups. Furthermore, no patient in any group needed chronic dialysis. In the GFR 40-49 group compared to the other groups, there was a trend for higher creatinine at 1 year but the baseline was high. Conclusion Baseline lower GFRs between 30-39 and 40-49 mL/min in MCS patients do not appear to be a predictor of poorer outcomes after HTx in patients. These patients do not appear to require combined heart and kidney transplantation.

Purpose Patients more than 50 years of age routinely undergo screening colonoscopies. These patients can develop severe end-stage heart disease and may require heart transplantation. Many of these patients present in cardiogenic shock and it is unclear whether the use of colonoscopy is safe and efficacious in the screening of these patients for candidacy for heart transplantation. In our single-center program, we preform colonoscopies routinely on older patients at risk for colon cancer (family history, previous polyps or adenomas, stools heme positive) awaiting heart transplantation. We now report our experience of performing colonoscopes in these patients who are in cardiogenic shock, defined as patients who are on intravenous inotropic or left ventricular assist device (LVAD) support to maintain acceptable cardiac hemodynamics. Methods Between 2014 and 2019, we evaluated 300 heart transplant candidates who developed cardiogenic shock, defined as the need for IV inotropes or LVAD support. 30 of these patients underwent colonoscopy while on IV inotropes (n=27) and LVAD (n=3). All patients had compensated hemodynamics and anticoagulation was held prior to the procedure. Results Of the 30 patients with inotropic/LVAD support who underwent colonoscopy, the average age was 61.5 years and 87% were male. The specific inotrope(s) administered are listed in the table. The following findings at colonoscopy were found: 0 adenomas and 13 benign malignancies. There was no metastatic disease demonstrated. There were no complications arising from this colonoscopy except for bleeding due to biopsies that required hemoclips but no blood transfusions. Inotropic/LVAD support was continued through these procedures. Conclusion Colonoscopies for evaluation of heart transplant candidates who are in cardiogenic shock are acceptable, but caution should be taken in terms of risk for bleeding. Colonoscopies in cardiogenic shock should be limited to patients who are at risk for colon cancer.

Purpose Heart-liver transplant (HLvTx) has been demonstrated to show an immune protective effect with the transplanted liver protecting the heart. There are several reports suggesting less rejection in the HLvTx group. It has not been established whether this benefit is present in the current era. Methods Between 2007 and 2017, we assessed 13 HLvTx patients compared to heart alone patients (HATx, n=758). Patients were assessed for freedom from 1-year rejection [acute cellular rejection (ACR) and antibody-mediated rejection (AMR)] and donor-specific antibodies (DSA). Other endpoints included 5-year survival and freedom from cardiac allograft vasculopathy (CAV, stenosis ≥30% by angiography) and non-fatal major adverse cardiac event (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke). Results HLvTx compared to HATx showed similar freedom from 1-year rejection (ACR, AMR) and DSA. 5-year survival, freedom from CAV and NF-MACE were also similar between the two groups (see table). Conclusion In the current era, HLvTx does not appear to provide immune protection in either rejection or CAV. A larger number of heart-liver transplant patients will be needed to confirm these findings.

Purpose Patients who are awaiting heart transplantation (HTx) have blood screened for circulating antibodies. Antibodies can sometimes come and go and not be detected at the time of HTx. However, there are instances when the patient has demonstrated donor specific antibodies (DSA) in the past but yet are not present at the time of HTx. It is not known whether these historical DSA have an impact on post-HTx outcomes. Methods Between 2010 and 2019, we assessed 11 patients awaiting HTx who had historical DSA but none detected at the time of HTx. These patients were compared to patients with DSA at the time of HTx and also compared to a non-sensitized group of patients undergoing HTx in a contemporaneous era. Post-HTx detection of DSA was performed and assessed if there was an amnestic response to the historical DSA. DSA are routinely checked post-HTx at 1, 3, 6, 12 months post-operatively. Other endpoints included 1-year freedom from any treated rejection, acute cellular rejection, and antibody-mediated rejection. 1-year survival, 1-year freedom from non-fatal major adverse cardiac event (NF-MACE, defined as MI, new CHF, PCI, ICD/pacemaker placement, stroke) and 1-year freedom from cardiac allograft vasculopathy were also recorded. Results Patients with historical DSA did not have an amnestic response with an increase of that specific DSA post-HTx. The historical DSA group compared to the non-sensitized group had no significant differences in 1-year survival, freedom from DSA, CAV, NF-MACE or rejections. Specifically, the historical DSA group did not appear to have an increase in any type of rejection in the first year post-HTx compared to (crossing) DSA at transplant group or the non-sensitized group. (See table) Conclusion Historical DSA does not appear to be a factor in terms of an amnestic response possibly due to the immunosuppression that is being administered. Therefore, crossing historical DSA at heart transplant does not appear to have adverse sequelae.

Purpose Sensitization occurs with blood transfusions in recipients of left ventricular assist device (LVAD). 30% of LVAD patients develop a panel reactive antibody (PRA) screen of >= 10%. Highly sensitized patients have an increased morbidity and mortality after heart transplantation. Desensitization therapy is considered for patients with PRAs> 50%. Below are the results of desensitization therapies in mechanical circulatory support (MCS) patients. Methods From 2010-2016, 49 MCS patients who underwent desensitization therapy were compared to a control group who underwent desensitization but did not have MCS support. Desensitization therapy used in both groups included combinations of rituximab/IVIG and plasmapheresis/bortezomib. Baseline PRAs prior to desensitization were repeated 2-4 weeks after treatment. For patients who underwent heart transplantation, outcomes included 1-year survival, freedom from cardiac allograft vasculopathy (CAV), freedom from non-fatal major adverse cardiac events (NF-MACE, defined as myocardial infarction, percutaneous coronary intervention, new congestive heart failure, pacemaker/implantable cardioverter-defibrillator placement, and stroke), and freedom from any treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR). Results Desensitization therapy was successful in both MCS and control groups, resulting in an average of 12% decrease in PRA. When subgrouped into Class 1 versus Class 2 antibodies, Class 1 antibodies appeared to have a better response after desensitization therapy (PRA decrease of 15% in Class 1 versus a decrease of 9% in Class 2). Patients on MCS support appear to have a numerical lower incidence of AMR with comparable first-year survival, freedom from CAV, NF-MACE, ATR, and ACR. Conclusion Desensitization of MCS patients appeared to be beneficial. Removal of the MCS device at the time of transplant may be a factor in potentially less AMR post-transplant.

Purpose Patients with end-stage heart failure may undergo mechanical circulatory support (MCS) as a bridge to transplant. This strategy may be complicated by sensitization due to blood transfusions as well as driveline infections. As sensitization narrows the donor pool, desensitization may be performed. The purpose of this study was to determine the impact of desensitization therapy on infections in MCS patients with an existing driveline infection. Methods We reviewed 45 MCS patients who developed a driveline infection between 2012-2018. Patients were divided into: sensitized (PRA >10%, n=22) and not sensitized (n=23). Sensitized patients were divided into: desensitization (when CPRA > 50%; n=7) and no desensitization (n=15). Desensitization included IVIG, rituximab, bortezomib and/or plasmapheresis. Outcomes were assessed 1 year after the driveline infection: survival, freedom from readmission, freedom from new driveline infection, and freedom from any infection. Results There was no difference between sensitized and non-sensitized MCS patients with a driveline infection in 1-year survival, freedom from readmissions, or freedom from any subsequent infection. There was no difference in outcomes between sensitized patients who received desensitization therapy and those who did not. Conclusion Desensitization appears to be safe in MCS patients with an existing driveline infection to potentially expand the compatible donor pool.

Purpose Increased perioperative risk has been observed in patients with left ventricular assist devices (LVAD) and total artificial hearts (TAH) undergoing heart transplantation with worse outcomes in TAH patients. The purpose of this study was to review perioperative transplant outcomes in TAH vs LVAD patients at a high-volume transplant center. Methods We reviewed perioperative transplant outcomes of 46 TAH patients and 85 LVAD patients from 2010-2018. Outcomes included perioperative transfusions (units of packed red blood cells, fresh frozen plasma, platelets, cryoprecipitate), time in the operating room (OR), intensive care unit (ICU) days immediately post-transplant, freedom from return to OR for bleeding, freedom from primary graft dysfunction (PGD), and 1-year freedom from temporary dialysis. In addition, 1-year outcomes included survival, freedom from cardiac allograft vasculopathy (CAV), freedom from non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, heart failure, percutaneous intervention, defibrillator/pacemaker implant, stroke), and freedom from first-year rejection (any treated rejection (ATR), acute cellular rejection (ACR), antibody-mediated rejection (AMR)). Results TAH patients had more perioperative blood transfusions, and had decreased freedom from return to the OR for bleeding, temporary dialysis, and NF-MACE. There were no differences between groups in the time in OR, ICU days post-transplant, and freedom from PGD, survival, CAV, and rejection. Conclusion TAH patients appear to have increased perioperative post-transplant risk for some parameters though no difference in PGD or survival compared to LVAD patients. In a high volume center, there can be acceptable post-transplant outcomes in TAH patients.

Purpose Thymoglobulin (ATG) is commonly used as induction therapy immediately after heart transplantation (HTx). ATG has been associated with an increase in CMV infection when used with maintenance cyclosporine. In the current era, tacrolimus has replaced cyclosporine as the main maintenance immunosuppressive agent. It is not clear whether ATG induction does indeed lead to more CMV infection in the tacrolimus era. Methods Between 2010 and 2016, we assessed 342 patients who received ATG induction therapy and compared them with HTx patients who did not receive ATG (n=312). ATG is routinely administered to patients with renal insufficiency to delay tacrolimus initiation and to sensitized patients (PRA ≥ 10%). Patients treated with ATG were then divided into their donor/recipient CMV serology matching (D+R-, D+R+, D-R+ and D-R-) and analyzed for the development of CMV infection defined as patients presenting with clinical symptoms and detected CMV virus via PCR. Incidence of rejection was also evaluated. Valcyte is routinely administered for CMV prophylaxis. Results There was a trend towards an increase in CMV infection in patients who received ATG induction therapy after HTx (see table). When the ATG population was analyzed by CMV serology, CMV mismatch (D+R-) had a numerical increase in CMV infection but this result was not statistically significant. When compared to the D-R- group on pairwise analysis, there was a trend towards increase in CMV infection and any-treated rejection in the CMV mismatch group (D+R-). (see table). Of note, valcyte induction was similar between groups per the transplant protocol. Conclusion ATG therapy trends towards increased CMV infection post-transplant in the tacrolimus era. Patients who have been treated with ATG and have CMV mismatch (D+R-) may have increased CMV infection risk as well as rejection risk by 2-years after HTx. Larger numbers are needed to confirm these findings.

Purpose Patients with muscular dystrophy may have an associated cardiomyopathy, resulting in advanced heart failure requiring transplantation. However, the skeletal muscle dysfunction can result in respiratory impairment, dysphagia, and inability to participate in rehabilitation after heart transplantation. The purpose of this study was to describe the characteristics and outcomes of muscular dystrophy patients undergoing heart transplantation at our center. Methods We reviewed patients at our center status post heart transplantation between 2010 and 2017. Of the 646 patients, we identified 10 with muscular dystrophy. The demographics, clinical characteristics, and outcomes of these 10 patients with muscular dystrophy were compared to the 646patients without muscular dystrophy transplanted during this time period. Results The muscular dystrophy patients were all deemed acceptable to proceed by a neurologist with expertise in muscular dystrophy. They were younger (45 years vs 56 years; p = 0.006); had younger donors (27 years vs 35 years, p = 0.05); had lower creatinine (0.95 mg/dL vs 1.15 mg/dL; P = 0.01); and less pre-transplant diabetes (13% vs 52%; p = 0.03). There was no difference in sensitization, CMV IgG mismatch status, or Status 1A listing. The muscular dystrophy patients had 100% 1- and 5-year survival (Figure) and there was no difference in the incidence of cellular rejection, antibody-mediated rejection, or allograft vasculopathy between groups. Conclusion Patients with muscular dystrophy-associated cardiomyopathy may require heart transplantation. This analysis indicates that carefully selected patients can have excellent outcomes and therefore should be considered candidates for advanced heart failure therapies.

Purpose Cytomegalovirus (CMV) has been documented as a risk factor for the development of cardiac allograft vasculopathy (CAV) after heart transplantation (HTx). It has not been firmly established whether CMV would cause an increase in first-year intimal thickening via intravascular ultrasound (IVUS) in the current tacrolimus era. First-year maximal intimal thickening (MIT) ≥0.5mm has been found to be predictive of poor outcome (worse survival, CAV) at 5-years post-transplant. In addition, there has not been a differentiation between CMV infection, CMV syndrome, and CMV disease as it applies to IVUS intimal thickening. CMV infection is noted by positive IgG CMV serology only; CMV syndrome refers to patients with documented CMV virus along with a clinical presentation; CMV disease is defined as organ-specific CMV infection i.e. CMV pneumonitis, CMV colitis etc. Therefore, we sought to use first-year IVUS to determine whether CMV infection, syndrome, or disease would lead to more first-year MIT ≥0.5mm. Methods Between 2010 and 2017, 294 heart transplant patients underwent baseline and 1-year IVUS. These patients were then divided into 4 groups: (Group A - no CMV infection (n=108); Group B - CMV infection (n=173); Group C - CMV syndrome (n=9); and Group D - CMV disease (n=3)). Diagnosis of CAV was based on a ≥ 0.5 mm increase in maximal intimal thickness (MIT) from baseline. Results Baseline MIT was similar among all study groups. The percent of patients with first-year MIT ≥0.5mm was also similar among all patient groups. Conclusion The development of CMV infection, syndrome and disease, does not appear to increase CAV risk by first-year MIT obtained by IVUS in the current tacrolimus era. Larger number of patients with longer follow-up studies are warranted to confirm these findings.

Purpose Certain donor characteristics after heart transplantation (HTx) may have less optimal outcome post-HTx. One factors leading to worse outcome is female donors to male recipient possibly due to size (height and weight) mismatch relative to male donors. We try to compensate for this size mismatch by using obese female donors into male recipients. However, there have been recent concerns with obese donors, in the sense that there are commonly large fat deposits on the donor heart. It is not known whether short and obese female donors (weight oversizing) results in acceptable outcome after HTx. We sought to assess for this possibility in our large single center. Methods Between 2010 and 2017 we assessed 799 HTx patients and divided them into those male recipients who received female donors (n=246) that were short (≤ 66 inches) and obese (BMI≥30) (n=61) and short and non-obese (BMI major adverse cardiac events (NF-MACE: myocardial infarction , new congestive heart failure , percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke), and freedom from any-treated rejection, acute cellular rejection , and antibody-mediated rejection . Results There is no significant difference in 1-year outcomes between short and obese female donors, short and non-obese female donors, and male donors of similar heights and weights (see tables). Conclusion Short and stout female donors appear to be acceptable for HTx which increases the donor pool.

Purpose Proliferation signal inhibitors (PSIs) have been shown to decrease the incidence of cardiac allograft vasculopathy (CAV) and rejection in clinical trials when given at the time of heart transplantation. These trials have also demonstrated that patients on PSIs have a reduced risk of CMV infection post-transplant. However, the effect of PSIs on overall infection rates when given later post-transplant has not been clearly delineated. We sought to evaluate the incidence of infection post-PSI initiation at our single center. Methods Between 2010 and 2015 we assessed 550 heart transplant patients, 187 of which were initiated on a PSI (sirolimus or everolimus) over a five-year period after heart transplant. Endpoints included subsequent 2-year survival and subsequent 2-year freedom from infection (including CMV). A control population with patients not initiated on a PSI (n=363) was also included. Results 187/550 (34.0%) of heart transplant patients were initiated on a PSI over a five-year period after heart transplant. Patients were initiated on a PSI due to rejection, malignancy, CMV viremia, CAV, circulating antibodies, renal insufficiency and infection. The average time to PSI initiation was 1.3 years. Patients on a PSI compared to patients on no PSI had significantly reduced subsequent 2-year survival and reduced subsequent 2-year freedom from infection (see table). There was no difference in subsequent 2-year freedom from CMV infection. Conclusion PSI initiation later after heart transplant is associated with less than optimal outcomes. However, as PSI is used in high-risk patients, the outcomes are not unexpected but PSI use may have increased infection risk. PSI should be used with caution in these patients.

Purpose The Model for End-Stage Liver Disease (MELD) has been used to assess risk in patients awaiting liver transplant. More recently, MELD has been applied to patients with end-stage heart disease and has been demonstrated to reveal patients at high risk for mortality after heart transplantation (HTx). It is not known whether MELD score can predict severe PGD as per the new ISHLT scale. Methods Between 2010 and 2017, we identified 25 heart transplant patients who developed severe PGD supported by ECMO. This group was compared to 670 patients who did not have PGD. The pre-transplant MELD score was calculated for each group to see if there was a correlation to PGD. Results The MELD score was similar between patients that developed PGD and those that did not develop PGD (see table). Characteristics of the two groups demonstrated that the MELD individual criteria revealed that pre-transplant creatinine and total bilirubin were higher in the No PGD group but did not result in a difference between group MELD scores. Conclusion The MELD score may predict poor outcome after HTx; however, it does not appear to be a predictor for PGD.

Purpose The waiting time for heart transplantation can be long. Patients that are deemed ineligible for heart transplantation may become candidates due to the beneficial effects of MCS. Choosing to bridge with a short-term temporary device or a long-term durable device is a very important decision. We sought to evaluate the outcome of patients who were bridged with temporary versus durable MCS devices. Methods Between 2010 and 2017, we assessed 52 patients that were placed on temporary MCS devices (IABP, Impella, and ECMO) and 150 patients that were bridged with durable devices (LVAD, BiVAD, and TAH) prior to heart transplantation. A control non-bridged population was included (n=521). Endpoints included 30-day, 6-month and 1-year survival; 1-year freedom from cardiac allograft vasculopathy (CAV) as defined by stenosis ≥ 30% by angiography; 1-year freedom from non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke); and 1-year freedom from any-treated rejection, acute cellular rejection and antibody-mediated rejection. Results There was no significant difference in survival, CAV, NF-MACE, or rejection between patients bridged with temporary and durable MCS devices. Conclusion Bridging with either temporary or long-term durable devices appears to have great outcome. A larger sample size is needed to confirm these findings.

Purpose Cardiac allograft vasculopathy (CAV) is one of the major factors limiting long-term survival after HTx. The use of angioplasty and drug-eluting stents is common after HTx. CAV of the left main (LM) coronary artery is known to have high mortality risk. The long-term outcome of stenting for LM disease has not been well evaluated in this cohort of patients. Methods Between 2010 and 2013 we assessed 37 heart transplant patients who underwent stenting of the LM coronary artery post-transplant. A non-left main (no LM disease with another coronary artery stented) population was included (n=27) for comparison. Outcomes included 5-year freedom from restenosis (≥50% stent stenosis) subsequent 5-year survival, subsequent 5-year freedom from any myocardial infarction , and subsequent 5-year freedom from further deterioration in left ventricular function by echocardiogram . Results Subsequent 5-year freedom from restenosis and freedom from further deterioration in LV function was significantly lower in the LM stented group (see table). There was no difference in subsequent 5-year survival or freedom from myocardial infarction. Conclusion Patients with left main stenting appear to be have acceptable survival after heart transplantation despite progression to a lower left ventricular function and more restenosis. Alternatives to treatment for significant LM disease such as coronary bypass surgery and re-transplantation are not practical options in this diffuse disease and scarcity of donor hearts.

Modified BMI Does Not Predict Adverse Outcomes in Patients With Cardiac Amyloid Undergoing Heart Transplantation: A Report From iCCAT (International Consortium for Cardiac Amyloid Transplantation) M. Vaduganathan ,1 S. Tabtabai,1 J.K. Steiner,1 J.R. Stone,1 J.D. Estep,2 R.M. Witteles,3 G. Feltrin,4 M.J. Zucker,5 D.A. Baran,5 D.C. Seldin,6 J. Patel,7 M. Hanna,8 A. Cordero-Reyes,2 V. Selby,9 M.J. Semigran,1 M.S. Maurer.10 1Massachusetts General Hospital, Boston, MA; 2The Methodist Hospital, Houston, TX; 3Stanford University School of Medicine, Stanford, CA; 4University of Padua, Padua, Italy; 5Newark Beth Israel Medical Center, Newark, NJ; 6Boston University School of Medicine, Boston, MA; 7Cedars-Sinai Heart Institute, Los Angeles, CA; 8Cleveland Clinic, Cleveland, OH; 9University of California San Francisco, San Francisco, CA; 10New York-Presbyterian Hospital / Columbia University Medical Center, New York, NY.

Purpose Coronary allograft vasculopathy (CAV) remains an important contributor of mortality following orthotopic heart transplantation (OHT). Prevalence of epicardial coronary stenosis ≥30% at 5 years post OHT is reported to be 30%. The purpose of this study was to define the prevalence of CAV in a contemporary cohort. Methods and Materials We studied 432 consecutive coronary angiograms of patients transplanted from 1994-2011 (87.3% transplanted after January 2000). Baseline characteristics were obtained from medical records. CAV status was classified according to the International Society for Heart and Lung Transplantation grading report: mild (CAV1), moderate (CAV2), or severe (CAV3). Unpaired t test and Fisher’s exact test were used for statistical analysis. Results During a mean angiographic follow-up period of 5.2±4.3 years (all follow-up ≥1 year), angiographic stenosis ≥30% was identified in 70 (16%) patients. Mean time to development of epicardial coronary stenosis ≥30% was 5.8±3.9 years. Prevalence of coronary stenosis ≥30% at 1 year was 1.6%, at 3 years 6.3%, at 5 years 8.3%, and at 10 years 14.1%. CAV1 severity was identified in 33 (7.6%) patients, CAV2 in 25 (5.8%) patients and CAV3 in 12 (2.8%) patients. Percutaneous coronary intervention was necessary in 5.8% of all patients. Mean transplant age (55±12 years), donor age (32±12 years), gender (22% female), ischemic time (185±70 minutes) and choice of calcineurin inhibitor (tacrolimus vs cyclosporine) were not significantly different between patients with and without CAV. Patients with CAV were more likely to have had cellular or humoral rejection within the first year of transplant than patients without CAV [13/70 (19%) vs 25/362 (6.9%), p=0.0043]. Conclusions The prevalence of allograft vasculopathy appears to have decreased in a large contemporary cohort compared to prior reports. Rejection continues to play a role in CAV formation but may not be the only contributing factor. Further investigation is warranted to ascertain which aspect(s) of clinical care has contributed to this positive outcome.