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Background The COVID-19 pandemic has reduced access to endomyocardial biopsy (EMBx) rejection surveillance in heart transplant (HT) recipients. This is the first Canadian study to assess the role for non-invasive rejection surveillance in personalizing titration of immunosuppression (IS) and patient satisfaction post-HT. Methods In this mixed methods prospective cohort study, adult HT recipients more than six months from HT had their routine EMBx replaced by non-invasive rejection surveillance with gene expression profiling (GEP) and donor-derived cell-free DNA (dd-cfDNA). Demographics, outcomes of non-invasive surveillance score, hospital admissions, patient satisfaction, and health status on Medical Outcomes Study 12-item Short Form Health Survey (SF-12) were collected and analyzed using t -tests and chi-squared tests. Thematic qualitative analysis was performed for open-ended responses. Results Among 90 patients, 31 (33%) were enrolled. 36 combined tests were performed; 22 (61%) were -GEP/-dd-cfDNA, 10 (27%) had +GEP/-dd-cfDNA, 4 (11%) had -GEP/+dd-cfDNA and 0 +GEP/+dd-cfDNA. All patients with a positive dd-cfDNA (range 0.19-0.81%) underwent EMBx with no significant cellular or antibody mediated rejection. 15 cases (42%) had IS reduction and this increased to 55% in patients with negative concordant testing. Overall, patients’ reported satisfaction was 90% and on thematic analysis they were more satisfied with less anxiety during the non-invasive testing experience. Conclusions Non-invasive rejection surveillance was associated with the ability to lower immunosuppression, increase satisfaction, and reduce anxiety in heart transplant recipients, minimizing exposure for patients and providers during a global pandemic.

Background and Aim of Study There exists controversy regarding the impact of infection in patients with a left ventricular assist device (LVAD) on post‐heart transplant outcomes. This study evaluated the association between infections during LVAD support and the risk of early and late post‐heart transplant infection, rejection, and mortality in transplant recipients bridged with an LVAD. Methods This is a single‐center retrospective observational cohort study of consecutive adults supported with a continuous flow LVAD undergoing heart transplant between 2006 and 2019 at the Toronto General Hospital. The grade of LVAD infection was classified as per International Society of Heart and Lung Transplantation guidelines. Patients were divided into three groups: (1) patients with LVAD‐specific infection confirmed with positive cultures requiring long‐term antibiotic use until the time of transplant; (2) patients with any type of infection in whom antibiotics were stopped at least 1 month before transplant; (3) patients without any infections between LVAD implant and transplant. Logistic regression and Cox proportional hazard models were used to evaluate early‐ and late‐post transplant outcomes, respectively. Results We included 75 LVAD recipients: 16 (21%) patients had a chronic LVAD‐related infection on suppressive antibiotics, 30 (40%) had a resolved infection, and 29 (39%) had no infections. During a median post‐transplant follow‐up time of 4 (2 to 7) years, 65 (87%) patients developed infections, 43 (64%) rejections, and 17 (23%) deaths. Both short‐ and long‐term risks of infection, rejection, and mortality did not differ significantly among the groups. Conclusion LVAD patients with infections did not have a significantly higher risk of infection, rejection, or mortality at any time point after transplant.