The Heart Awakens

Abstract

<h3>Introduction</h3> Primary graft dysfunction (PGD) after orthotopic heart transplant (OHT) can be a challenging complication to manage. We present a 70 year-old male with severe PGD immediately after OHT that required mechanical circulatory support. <h3>Case Report</h3> The patient developed myocarditis at age 63 leading to dilated cardiomyopathy. By age 69, despite guideline-directed medical therapy, he required a HeartMate 3 ventricular assist device (VAD) as a bridge to transplant for progressive heart failure. He was discharged and listed for OHT. Five months later, he was admitted for ventricular tachycardia storm and his listing status was upgraded. After 3 days, a donor organ with mild left ventricular (LV) systolic dysfunction was accepted for OHT. Intra-operatively, the transplanted heart showed limited contractility, despite epicardial pacing (cross clamp time 237 minutes, warm ischemic time 60 minutes). Therefore, biventricular CentriMag VADs were implanted. Post-operative ECG showed a slow ventricular escape rhythm (Figure 1A). On post-operative day (POD) 5, due to left hemothorax, he returned to the operating room, where improved cardiac contractions were noted. Serial cardiac biopsies showed normal myocardium and no rejection (Figure 1B, 1D). Over the next 2 days, the heart regained contractility. ECG showed a junctional escape rhythm (Figure 1C). On POD 7, the transplanted heart showed recovery and the Centrimag VADs were explanted. By POD 12, he was weaned off vasoactive medications and transferred to the ward. Eventually, on POD 23, he was discharged home with a permanent pacemaker. <h3>Summary</h3> This case demonstrates severe PGD in the context of pre-existing mild donor LV dysfunction that was successfully managed by mechanical circulatory support as a bridge to recovery. A potential contributor to graft dysfunction may be myocyte stunning by antiarrhythmic medications infused pre-operatively for ventricular tachycardia storm. This case shows the utility of donor hearts with LV systolic dysfunction even in the presence of other risk factors for PGD.