Heart transplant complications: Difference between revisions
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**Resting rate between 90-100 bpm | **Resting rate between 90-100 bpm | ||
**Response to exertion/stress is blunted by lack of central mediated tachycardia, though can still respond to circulating catecholamines | **Response to exertion/stress is blunted by lack of central mediated tachycardia, though can still respond to circulating catecholamines | ||
**Upregulation of catecholamine receptors | |||
**[[Atropine]] is ineffective (no Vagal nerve tone) | |||
{{Immunosuppressant medication complications}} | {{Immunosuppressant medication complications}} | ||
| Line 11: | Line 13: | ||
*Patients monitored with surveillance biopsies regularly | *Patients monitored with surveillance biopsies regularly | ||
*Spectrum of presentations, anywhere asymptomatic to in extremis | *Spectrum of presentations, anywhere asymptomatic to in extremis | ||
**Features include | **Features include [[dysrhythmias]], decreased exercise tolerance, and [[infection]] may be clues | ||
===Infection=== | ===Infection=== | ||
*Increased risk of opportunistic/severe [[infections]] | |||
* | *[[Fever]] and other classic features may be absent due to immunosuppression | ||
===Signs/Symptoms of Congestive Heart Failure=== | |||
===Signs/Symptoms of [[Congestive Heart Failure]]=== | |||
*Due to various etiologies | *Due to various etiologies | ||
*MI may present only with CHF symptoms | *[[MI]] may present only with CHF symptoms | ||
===Medication Adverse Effects=== | ===Medication Adverse Effects=== | ||
*Prednisone | *[[Prednisone]] | ||
**Hyperglycemia, psychiatric symptoms, poor wound healing, edema, hypertension | **[[Hyperglycemia]], psychiatric symptoms, poor wound healing, edema, [[hypertension]] | ||
*Tacrolimus, cyclosporine | *[[Tacrolimus]], [[cyclosporine]] | ||
**Neurotoxicity, tremor, hyperkalemia, nephrotoxicity, hypertension, hyperglycemia, gout | **Neurotoxicity, [[tremor]], [[hyperkalemia]], [[AKI|nephrotoxicity]], [[hypertension]], [[hyperglycemia]], [[gout]] | ||
*Mycophenolate | *[[Mycophenolate]] | ||
**Cytopenias, GI distress | **Cytopenias, [[nausea/vomiting|GI distress]] | ||
*Azathioprine | *[[Azathioprine]] | ||
**Cytopenias, pancreatitis, hepatitis | **Cytopenias, [[pancreatitis]], [[hepatitis]] | ||
===[[Myocardial ischemia]]/CAD=== | ===[[Myocardial ischemia]]/CAD=== | ||
*Pediatric recipients in particular at risk for graft CAD | *Pediatric recipients in particular at risk for graft CAD | ||
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''Workup dependent on presentation, considerations include:'' | ''Workup dependent on presentation, considerations include:'' | ||
*CBC, BMP, Mg/Phos | *CBC, BMP, Mg/Phos | ||
*Low | *Low threshold for infectious workup, including viral/fungal studies | ||
*Tacrolimus, cyclosporine levels | *Tacrolimus, cyclosporine levels | ||
*[[ECG]] | *[[ECG]] | ||
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***→ two P waves on ECG | ***→ two P waves on ECG | ||
***donor P wave will be in 1:1 relationship with QRS, native P wave has independent rhythm | ***donor P wave will be in 1:1 relationship with QRS, native P wave has independent rhythm | ||
*[[CXR | *[[CXR]] | ||
**May | **May have relative "cardiomegaly" if donor was much larger than recipient | ||
*CT Chest | *CT Chest | ||
**May be required to diagnose PE, hypoxemia, pneumonia | **May be required to diagnose PE, hypoxemia, pneumonia | ||
* | *[[Echocardiography]] | ||
**Consider if signs/symptoms of heart failure | **Consider if signs/symptoms of heart failure | ||
==Management Considerations== | ==Management Considerations== | ||
*Consult/discuss with transplant team | *Consult/discuss with transplant team | ||
| Line 54: | Line 58: | ||
**Do not treat if stable, as steroids will muddy biopsy results | **Do not treat if stable, as steroids will muddy biopsy results | ||
**[[Methylprednisolone]] 1g IV if in extremis | **[[Methylprednisolone]] 1g IV if in extremis | ||
* | *Dysrhythmias | ||
**[[Bradycardia]] will ‘’’NOT’’’ respond to atropine due to denervation | **[[Bradycardia]] will ‘’’NOT’’’ respond to atropine due to denervation | ||
***transplant patients with symptomatic bradycardia may respond to isoproterenol 1 μg/min, titrated slowly to max 4 μg/min | ***transplant patients with symptomatic bradycardia may respond to isoproterenol 1 μg/min, titrated slowly to max 4 μg/min | ||
| Line 65: | Line 69: | ||
==See Also== | ==See Also== | ||
*[[Transplant complications]] | *[[Transplant complications]] | ||
*[[Neutropenic fever]] | |||
*[[Immunocompromised antibiotics]] | |||
*[[In-Training Exam Review]] | |||
==External Links== | ==External Links== | ||
Latest revision as of 19:57, 8 March 2021
Background
- Indications: end-stage heart failure refractory to standard medical/surgical treatment
- Transplanted heart is denervated
- Resting rate between 90-100 bpm
- Response to exertion/stress is blunted by lack of central mediated tachycardia, though can still respond to circulating catecholamines
- Upregulation of catecholamine receptors
- Atropine is ineffective (no Vagal nerve tone)
Immunosuppressant Medications
- Balance between immune suppression, rejection and susceptibility to infection
- Typical regimen includes: calcineurin inhibitor + antimetabolite + steroid
- Calcineurin inhibitor
- Steroids
- +/- Antimetabolite
Clinical Features
Rejection
- Patients monitored with surveillance biopsies regularly
- Spectrum of presentations, anywhere asymptomatic to in extremis
- Features include dysrhythmias, decreased exercise tolerance, and infection may be clues
Infection
- Increased risk of opportunistic/severe infections
- Fever and other classic features may be absent due to immunosuppression
Signs/Symptoms of Congestive Heart Failure
- Due to various etiologies
- MI may present only with CHF symptoms
Medication Adverse Effects
- Prednisone
- Hyperglycemia, psychiatric symptoms, poor wound healing, edema, hypertension
- Tacrolimus, cyclosporine
- Neurotoxicity, tremor, hyperkalemia, nephrotoxicity, hypertension, hyperglycemia, gout
- Mycophenolate
- Cytopenias, GI distress
- Azathioprine
- Cytopenias, pancreatitis, hepatitis
Myocardial ischemia/CAD
- Pediatric recipients in particular at risk for graft CAD
- Due to denervation, transplant patients with ’’’NOT’’’ have pain with ACS
Differential Diagnosis
Evaluation
Workup dependent on presentation, considerations include:
- CBC, BMP, Mg/Phos
- Low threshold for infectious workup, including viral/fungal studies
- Tacrolimus, cyclosporine levels
- ECG
- Patient’s native sinus node often preserved
- → two P waves on ECG
- donor P wave will be in 1:1 relationship with QRS, native P wave has independent rhythm
- Patient’s native sinus node often preserved
- CXR
- May have relative "cardiomegaly" if donor was much larger than recipient
- CT Chest
- May be required to diagnose PE, hypoxemia, pneumonia
- Echocardiography
- Consider if signs/symptoms of heart failure
Management Considerations
- Consult/discuss with transplant team
- Rejection
- Diagnosed by biopsy
- Do not treat if stable, as steroids will muddy biopsy results
- Methylprednisolone 1g IV if in extremis
- Dysrhythmias
- Bradycardia will ‘’’NOT’’’ respond to atropine due to denervation
- transplant patients with symptomatic bradycardia may respond to isoproterenol 1 μg/min, titrated slowly to max 4 μg/min
- Transplant patients may be overly sensitive to adverse effects from adenosine
- Sinus node dysfunction usually requires pacemaker placement
- Bradycardia will ‘’’NOT’’’ respond to atropine due to denervation
- See Immunocompromised antibiotics