Heart transplant complications: Difference between revisions

Latest revision as of 19:57, 8 March 2021

Background

Indications: end-stage heart failure refractory to standard medical/surgical treatment
Transplanted heart is denervated
- Resting rate between 90-100 bpm
- Response to exertion/stress is blunted by lack of central mediated tachycardia, though can still respond to circulating catecholamines
- Upregulation of catecholamine receptors
- Atropine is ineffective (no Vagal nerve tone)

Immunosuppressant Medications

Balance between immune suppression, rejection and susceptibility to infection
Typical regimen includes: calcineurin inhibitor + antimetabolite + steroid
- Calcineurin inhibitor
  - Cyclosporine
  - Tacrolimus
- Steroids
  - Prednisone/Prednisolone
- +/- Antimetabolite
  - Azathioprine
  - Mycophenolate mofetil (MMF)

Clinical Features

Rejection

Patients monitored with surveillance biopsies regularly
Spectrum of presentations, anywhere asymptomatic to in extremis
- Features include dysrhythmias, decreased exercise tolerance, and infection may be clues

Infection

Increased risk of opportunistic/severe infections
Fever and other classic features may be absent due to immunosuppression

Signs/Symptoms of Congestive Heart Failure

Due to various etiologies
MI may present only with CHF symptoms

Medication Adverse Effects

Prednisone
- Hyperglycemia, psychiatric symptoms, poor wound healing, edema, hypertension
Tacrolimus, cyclosporine
- Neurotoxicity, tremor, hyperkalemia, nephrotoxicity, hypertension, hyperglycemia, gout
Mycophenolate
- Cytopenias, GI distress
Azathioprine
- Cytopenias, pancreatitis, hepatitis

Myocardial ischemia/CAD

Pediatric recipients in particular at risk for graft CAD
Due to denervation, transplant patients with ’’’NOT’’’ have pain with ACS

Differential Diagnosis

Evaluation

Workup dependent on presentation, considerations include:

CBC, BMP, Mg/Phos
Low threshold for infectious workup, including viral/fungal studies
Tacrolimus, cyclosporine levels
ECG
- Patient’s native sinus node often preserved
  - → two P waves on ECG
  - donor P wave will be in 1:1 relationship with QRS, native P wave has independent rhythm
CXR
- May have relative "cardiomegaly" if donor was much larger than recipient
CT Chest
- May be required to diagnose PE, hypoxemia, pneumonia
Echocardiography
- Consider if signs/symptoms of heart failure

Management Considerations

Consult/discuss with transplant team
Rejection
- Diagnosed by biopsy
- Do not treat if stable, as steroids will muddy biopsy results
- Methylprednisolone 1g IV if in extremis
Dysrhythmias
- Bradycardia will ‘’’NOT’’’ respond to atropine due to denervation
  - transplant patients with symptomatic bradycardia may respond to isoproterenol 1 μg/min, titrated slowly to max 4 μg/min
- Transplant patients may be overly sensitive to adverse effects from adenosine
- Sinus node dysfunction usually requires pacemaker placement
See Immunocompromised antibiotics

Disposition

External Links

References

Authors:

@@ Line 1: / Line 1: @@
 ==Background==
+*Indications: end-stage [[heart failure]] refractory to standard medical/surgical treatment
+*Transplanted heart is denervated
+**Resting rate between 90-100 bpm
+**Response to exertion/stress is blunted by lack of central mediated tachycardia, though can still respond to circulating catecholamines
+**Upregulation of catecholamine receptors
+**[[Atropine]] is ineffective (no Vagal nerve tone)
+{{Immunosuppressant medication complications}}
 ==Clinical Features==
+===Rejection===
+*Patients monitored with surveillance biopsies regularly
+*Spectrum of presentations, anywhere asymptomatic to in extremis
+**Features include [[dysrhythmias]], decreased exercise tolerance, and [[infection]] may be clues
+===Infection===
+*Increased risk of opportunistic/severe [[infections]]
+*[[Fever]] and other classic features may be absent due to immunosuppression
+===Signs/Symptoms of [[Congestive Heart Failure]]===
+*Due to various etiologies
+*[[MI]] may present only with CHF symptoms
+===Medication Adverse Effects===
+*[[Prednisone]]
+**[[Hyperglycemia]], psychiatric symptoms, poor wound healing, edema, [[hypertension]]
+*[[Tacrolimus]], [[cyclosporine]]
+**Neurotoxicity, [[tremor]], [[hyperkalemia]], [[AKI|nephrotoxicity]], [[hypertension]], [[hyperglycemia]], [[gout]]
+*[[Mycophenolate]]
+**Cytopenias, [[nausea/vomiting|GI distress]]
+*[[Azathioprine]]
+**Cytopenias, [[pancreatitis]], [[hepatitis]]
+===[[Myocardial ischemia]]/CAD===
+*Pediatric recipients in particular at risk for graft CAD
+*Due to denervation, transplant patients with ’’’NOT’’’ have pain with [[ACS]]
 ==Differential Diagnosis==
-==Diagnosis==
+==Evaluation==
+''Workup dependent on presentation, considerations include:''
+*CBC, BMP, Mg/Phos
+*Low threshold for infectious workup, including viral/fungal studies
+*Tacrolimus, cyclosporine levels
+*[[ECG]]
+**Patient’s native sinus node often preserved
+***→ two P waves on ECG
+***donor P wave will be in 1:1 relationship with QRS, native P wave has independent rhythm
+*[[CXR]]
+**May have relative "cardiomegaly" if donor was much larger than recipient
+*CT Chest
+**May be required to diagnose PE, hypoxemia, pneumonia
+*[[Echocardiography]]
+**Consider if signs/symptoms of heart failure
-==Management==
+==Management Considerations==
+*Consult/discuss with transplant team
+*Rejection
+**Diagnosed by biopsy
+**Do not treat if stable, as steroids will muddy biopsy results
+**[[Methylprednisolone]] 1g IV if in extremis
+*Dysrhythmias
+**[[Bradycardia]] will ‘’’NOT’’’ respond to atropine due to denervation
+***transplant patients with symptomatic bradycardia may respond to isoproterenol 1 μg/min, titrated slowly to max 4 μg/min
+**Transplant patients may be overly sensitive to adverse effects from [[adenosine]]
+**Sinus node dysfunction usually requires pacemaker placement
+*See [[Immunocompromised antibiotics]]
 ==Disposition==
 ==See Also==
+*[[Transplant complications]]
+*[[Neutropenic fever]]
+*[[Immunocompromised antibiotics]]
+*[[In-Training Exam Review]]
 ==External Links==
@@ Line 17: / Line 77: @@
 ==References==
 <references/>
+[[Category:Cardiology]]