969-98 Biopsy Negative Left Ventricular Dysfunction After Cardiac Transplantation: Outcome and Role of Enhanced Immunosuppression

Abstract

To evaluate the incidence and etiology of LV dysfunction (LVD) occurring without cellular rejection after cardiac transplantation (CT), we retrospectively reviewed all echocardiograms from 93 consecutive CT recipients at Massachusetts General Hospital. A decrease in LVEF to <0.45 in the absence of secondary causes occurred in 15 patients (pts) (13 M, 2 F). RV biopsies (bx) showed moderate cellular rejection (ISHLT grade 2 to 3A) in 4/15 patients; 3/4 pts improved following therapy with enhanced immunosuppression (ENIM). Diagnostic studies in the 11 pts without cellular rejection included LV bx 15 pts) and immunofluorescence staining for vascular rejection (4 pts); all were negative. Coronary angiography was performed in 10/11 pts and revealed mild distal disease in 2 pts. These 2 pts died within four months of angiography, and had diffuse coronary artery disease (CAD) at autopsy. Change in LVEF over time in the 9 pts without CAD were: Initial (n = 9) LVD (n = 9) Current (survivors) (n = 6) Months After CT 0.4 ± 0.3 8.3 ± 7.8 47.8 ± 15 LVEF 0.64 ± 0.07 0.31 ± 0.09 053 ± 0.09 LV function improved spontaneously in 1 pI. The remaining 8 pts received ENIM for presumed rejection. Therapy included solumedrol in 7/8 pts. OKT3 in 4/8 pts, and actinomycin 2/8 pts. LVEF improved in 5/8, but returned to initial baseline only in 2 pts; 3 pts died within 2 months of presentation, despite therapy. In summary: 1. LV dysfunction, unexplained by cellular rejection or angiographic evidence of coronary disease, occurred in 10% of pts within 2 years of CT. 2. Despite negative histology, LVEF improved in 62% of these pts treated with enhanced immunosuppression.