Reversal of Cardiac Allograft Dysfunction with Medical Therapy

Abstract

Background Acute cellular rejection (ACR) among heart transplant recipients is common with up to 20% to 40% of patients developing an episode in the first year. Yet, stability is the norm after the first year. Late graft dysfunction is less common and can result in the need for re-transplantation. We present a case in which medical therapy was used in lieu and resulted in resolution of graft dysfunction. Case report A 48 year old man who underwent orthotopic heart transplant in July 2014 had an uncomplicated early transplant course with negative endomyocardial biopsy (EMBx) for allograft rejection through 21 months. At that time he presented with dyspnea, lower extremity swelling and excess sinus tachycardia (140 bpm). Given new heart failure symptoms, rejection evaluation was completed, including EMBx. Pathology revealed International Society for Heart and Lunt Transplantation (ISHLT) grade 2R ACR. Staining for antibody mediated rejection was negative. An echocardiogram (TTE) revealed a decline in allograft function from 70% to 40% with restrictive filling pattern. Treatment with anti-thymocyte globulin, high dose prednisone taper, plasmapheresis and bortezomib was given. Despite treatment the patient returned for heart failure hospitalization 3 months later. Right heart catheterization (RHC) showed pulmonary capillary wedge pressure of 24 mmHg, mean right atrial pressure of 12 mmHg and cardiac index of 1.9 L/min/m^2. Due to reluctance on the part of the patient to immediately consider re-transplantation, intravenous milrinone and titration of guideline-directed medical therapy was completed. Fortunately, the graft ejection fraction normalized on subsequent TTE and he was successfully weaned off milrinone over 5 months. Repeat RHC showed normal filling pressures and normal cardiac index. Conclusions Patients who develop graft dysfunction with cellular rejection may continue to experience residual graft dysfunction after treatment. Continued medical therapy with standard heart failure regimen and inotropes helped support this patient during decompensation. This case suggests the possibility of late allograft recovery with medical support and avoidance of re-transplantation. Further research is needed regarding effective medical management of graft dysfunction.