Heart transplant complications

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

Immunosuppressant Medications

Clinical Features

Rejection

  • Patients monitored with surveillance biopsies regularly
  • Spectrum of presentations, anywhere asymptomatic to in extremis
    • Features include dysrythmias, 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 threshhold 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
  • CXR
    • May have relative "cardiomegaly" if donor was much larger than recipient
  • CT Chest
    • May be required to diagnose PE, hypoxemia, pneumonia
  • Echo
    • 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
  • Dysrythmias
    • 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
  • See Immunocompromised antibiotics

Disposition

See Also

External Links

References