(1283) Covid-19 Associated Development of Antibody Mediated Rejection in Orthotopic Heart Transplantation Patients

INTRODUCTION: Solid organ transplant candidates encountered increased wait times and mortality rates during the COVID-19 pandemic. Despite improvement in medical management and vaccination efficacy, this patient population remains at increased risk for complications post COVID-19 including organ rejection. CASE REPORT: We describe 3 patients with prior orthotopic heart transplantation who developed acute cellular and antibody mediated rejection after either mild COVID-19 infection with or without antiviral treatment with remdesivir, or vaccination with various degrees of allograft dysfunction. Our patients were either asymptomatic despite increased filling pressures and/or abnormal non-invasive surveillance parameters or developed increasing heart failure symptoms. All patients in this case series, developed de novo class II donor specific antibodies within a short period of weeks to few months after COVID-19 exposure despite being on a stable regimen of immunosuppressive medication. All patients required a combined treatment for cellular and humoral rejection including high dose steroids, plasmapheresis, IVIG, bortezomib and rituximab. Immunosuppressive regimen was adjusted after treating for allograft rejection. SUMMARY: Patients with prior orthotopic heart transplantation seem to be at increased risk for rejection after exposure to the COVID-19 virus and close follow-up and monitoring is required for early detection of rejection. This series suggests that the risk of graft dysfunction is independent of the severity of COVID-19 symptoms, potential antiviral treatment or vaccination. Although centers have changed their management of outpatient follow-up for OHT patients, little is known on surveillance and management of OHT patients after COVID-19 infection. Immune dysregulation may persist for several months after COVID-19 infection and might impact immunosuppression management. Based on our experience, we have modified our post COVID surveillance protocols.