In the Current Era, Do We Have Improved Outcomes in Hemodynamic Compromise Rejection after Heart Transplantation?

Abstract

<h3>Purpose</h3> Hemodynamic compromise rejection (HCR) is seen <5% of heart transplantation (HTx) patients. HCR is defined as echocardiographic left ventricular ejection fraction ≤40% and pulmonary capillary wedge ≥15, cardiac index ≤2.0 and the requirement of inotropic support. Endomyocardial biopsy (EMB) done at the presentation of HCR does not always show biopsy proven rejection. With newer modalities of treatment in the current era, we sought to assess if there is now a different outcome in patients (pts) with HCR. <h3>Methods</h3> Between 2010-15, among 589 heart transplants, we identified 15 HTx pts (2.5%) who developed HCR. At the time of presentation of HCR, results of EMB were reviewed. Outcomes of these pts included subsequent 1-year survival, freedom from cardiac allograft vasculopathy (CAV, as defined by stenosis ≥30% by angiography), freedom from non-fatal major adverse cardiac event (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, defibrillator/pacemaker implant, stroke), and freedom from subsequent recurrence of rejection episodes, including any treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR). The HCR group was compared to a case-controlled group with similar age, sex, time from transplant (n=39). <h3>Results</h3> HCR did not consistently show rejection with 64% revealing neither ACR nor AMR on biopsy slides. 27% showed ACR, 9% showed AMR and the remainder showed no rejection. In the HCR group, subsequent 1-year survival and freedom from NF-MACE was significantly compromised compared to the control group. Subsequent 1-year freedom from CAV and recurrent rejections were not significantly different. (table) <h3>Conclusion</h3> In a majority of HCR cases, EMB findings reveal no rejection which may be due to an atypical immune process. In the current era, outcomes from HCR continue to be compromised which suggest the need for a more aggressive approach to immunosuppression and management.