Introduction
Perioperative high-intensity immunosuppression has the theoretical benefit of reducing the risk of rejection following orthotopic heart transplant (OHT) (1–4), where several contemporary randomized trials that have evaluated the impacts of various induction therapy agents, have also come to disparate conclusions (5,8). Prior studies have demonstrated that patients with higher pre-transplant predicted risks of rejection may garner benefit from receiving induction immunotherapy (9,10). The current guidelines from the International Society of Heart and Lung Transplantation (ISHLT) recommend antibody-based induction immunosuppression as an alternative for patients at high risk of renal dysfunction or rejection (11), although predicting which patients carry sufficient risk remains challenging. Considering this uncertainty, many centers have developed their own protocols for induction therapy utilization. Institutional factors greatly influence outcomes following OHT (12, 14) and may also be key determinants in the likelihood of a patient to receive induction therapy as well as their odds of rejection. As such, our objective was to evaluate the degree of center variability in the utilization of induction therapy and its implications on clinical outcomes following OHT.