Introduction and ObjectiveAlthough the etiology of transplant coronary atherosclerosis (TCA), the major cause of long‐term morbidity and mortality in heart transplantation (tx), is unknown, several immunological and non‐immunological causes (innate immunity, inflammation, cell activation, coagulation) have been proposed. Our group and others found that high circulating levels of C‐reactive protein (CRP), a major soluble pattern recognition receptors (sPRR) in humans, associate with development and progression of native atherosclerosis and TCA; although the pathogenic role of different isotypes of CRP (native, non‐native and proinflammatory monomeric) in atheroprotection or atherogenesis remains unclear. Immunoglobulin (Ig) M natural antibodies (NAbs), another innate sPRR, conveys an atheroprotective function, since high titers of IgM anti‐phosphorylcholine (IgM anti‐PC) NAbs associate with reduced atherosclerosis. Our objective was to determine the protective role of sPRR, more specifically IgM anti‐PC, in TCA.MethodsAdult heart transplant patients (n=172; 5.2±1.0 serial biopsies/patient in first 3‐months post‐tx) followed 8.9±5.0 years were studied. CAV and CAV severity were evaluated with angiograms (5.3±1.0/patient). Percentage of microvascular IgM was calculated from double staining (IgM/CD31 or Ulex europaeus lectin). IgM and IgM anti‐ PC from biopsy eluates were evaluated with immunoblotting and ELISA. Analyses used logistic regression; and Kaplan‐Meier curves for different tertile groups.ResultsPatients had low (<30% positive microvessels in all biopsies; n=67), high (>50% positive microvessels in all biopsies; n=64) or oscillatory IgM (IgMosc; low and high in all biopsies; n=41). Steady high IgM had an atheroprotective effect at 1‐, 5‐ and 10‐years (p<0.001) post‐tx compared with steady low IgM; while IgMosc was only atheroprotective at 5‐years (p<0.04). To determine if IgM was bound to PC, we incubated biopsies with high IgM (n=5) with PC, CRP or albumin, and immunoblots from eluates showed that myocardial IgM was removed by PC and CRP but not albumin. ELISA studies of biopsy eluates confirmed IgM anti‐PC following PC (56.7±20.0 U/ml) and CRP (60.5±18.3 U/ml), but not albumin (0.0±0.0 U/ml) incubation. Immunohistochemistry of biopsies post‐elution showed a complete absence of IgM.ConclusionsAtheroprotective IgM antibodies are NAbs to PC and future research needs to demonstrate if enhancing IgM anti‐PC NAbs ameliorates TCA, and if native CRP enhances atheroprotection.