What Is the Optimal Post-Transplant Cardiac Screening for Transplant Recipients with a Non-Malignant Disease?

Abstract

Introduction There are no published cardiac screening guidelines specific to nonmalignant hematopoietic cell transplant (HCT) recipients. Historically, our program has performed cardiac screening on all transplant recipients, regardless of transplant indication. We performed a quality improvement audit to determine the utility of this practice. Objective Assess the utility of routine cardiac screening post HCT for nonmalignant patients. Methods We performed a retrospective chart review to determine the new pathologies detected by post-HCT ECHO and EKG performed on patients with nonmalignant disorders who underwent HCT at our center from January 1, 2008 – December 31, 2016. Patients were included if they had a nonmalignant disease and an electrocardiogram (EKG) and echocardiogram (ECHO) prior to transplant and at either three months post-transplant, one year and/or yearly thereafter. Results The mean follow-up for the cohort (n=88) was 25 months (range 3-93 mo). Average age was 97 months and transplant indications included: 37% bone marrow failure, 5% metabolic, 22% immune deficiency and 36% other. For these patients, a total of 632 EKGs and 501 ECHOs were reviewed. On average each patient received 2 screening ECHO's and EKGs, post-transplant. Only 1 patient had new cardiac finding on post-transplant cardiac screening. Prior to HCT, this patient, with I cell disease, had right bundle branch block. On post-transplant screening, he was noted to develop mild aortic valve regurgitation, with normal systolic function. Three patients developed new cardiac dysfunction detected on additional screening due to clinical symptoms. One patient developed pericardial effusion and ultimately required the placement of a window. Subsequently, his pericardial effusion resolved, and his cardiac function was normal at last check two years post HCT. Another developed left ventricle enlargement and decreased function secondary to a fungemia. This subsequently resolved following resolution of her infection and cardiac function was normal on her last evaluation. The third died of pulmonary hypertension and decreased ventricular function 22 months post HCT. His Day 100- and 1-year screenings were normal. His dysfunction was detected on additional scans due to clinical symptoms. Conclusion In patients with nonmalignant disorders and a normal pre-transplant cardiac evaluation, the development of post-transplant cardiac complications is rare. This is likely explained by the lack of cardiac toxic medications prior to transplantation or high dose cardiac irradiation during the preparative regimen. Disease specific prospective studies including assessing individual risk factors are needed to guide post-transplant cardiac screening in this widely diverse patient population.