Background: Pregnancy in heart transplant (HT) recipients with episodes of rejection or positive donor specific antibodies (DSA) is discouraged by all recommendations due to higher risk of complications. Although there is paucity of data for DSA trend during pregnancy in HT recipients, there is evidence of improvement of symptoms during pregnancy in some autoimmune diseases (1-3).

Case report: 23-year-old female who underwent HT due to post-myocarditis cardiomyopathy in June 2014, reported unplanned pregnancy in June 2022. She had a history of acute cellular (3R/3B) and humoral rejection (DSA major histocompatibility complex (HLA) class I, specificity A11, A30, B13, B35 and HLA class II, specificity DR3, DR15, DR51, DR52, DQ2, mean fluorescent intensity (MFI) 1000-13 300) in August 2017 which required mechanical circulatory support due to severe heart failure with multiorgan damage. She underwent pulse corticosteroid treatment, and 12 cycles of plasmapheresis with administration of rituximab, intravenous immunoglobulins, and thymoglobulin. After that she had persistent positive DSA, predominantly DQ2 (MFI up to 12200), and because of that was on quadruple immunosuppression (tacrolimus, mycophenolate (MMF), everolimus, prednisone) from October 2019 to July 2020 when MMF was discontinued due to gastrointestinal side effects. She had one more cellular rejection episode (2R/3A) in March 2022 which was treated with pulse corticosteroids. During pregnancy she was on tacrolimus, everolimus, and prednisone combination with closely monitoring of immunosuppressants concentrations. Echocardiography controls showed normal left ventricle function and mildly reduced right ventricle function, NT-proBNP was slightly elevated (493-823 ng/L) and DSA were in a downward trend which is shown in Figure 1. At 32+3 weeks of pregnancy, she was hospitalized due to early labor. The following day male baby was delivered by Caesarean section due to pathological cardiotocography (Apgar score 8/9). After delivery DSA remained weakly positive.

Conclusion: Although pregnancy in HT recipients with history of rejection and positive DSA is discouraged, positive outcome is possible with close monitoring of multidisciplinary team. Furthermore, we described a rare case of downward trend of positive DSA during pregnancy.