Antibodies against Angiotensin II Type 1 Receptor (AT1R-Abs) have been associated with allograft rejection in heart transplantation. Data is lacking for modalities to mitigate their effect on cardiac function. We describe a case series consisting of patients with clinical and/or biopsy indication of rejection with detectable AT1R-Ab and present treatment regimen and outcome. Clinical dysfunction was defined as hemodynamically significant cardiac dysfunction on echocardiogram including a decrease in ejection fraction greater than or equal to 20%, shortness of breath, palpitations, chest tightness, and/or prolonged inotrope/vasopressor requirements during hospitalization. All patients selected for AT1R-Ab assessment had very low level or no donor specific HLA antibodies. Five of 9 patients with positive AT1R-Ab recovered good graft function following treatment with either losartan alone or in combination with plasmapheresis and IVIG. Two patients did not recover normal graft function and died despite the use of similar treatments. Losartan and plasmapheresis are obvious therapeutic approaches for heart transplant recipients with clinical dysfunction and positive AT1R-Ab. Losartan blocks activation of AT1 receptor, and plasmapheresis reduces circulating antibodies. Additional considerations such as patient characteristics, comorbidities, the use of ARBs other than losartan and appropriate time for treatment administration need to be evaluated in larger studies.
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