Heart transplant complications: Difference between revisions
 
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==Background==
==Background==
{{Transplant emergency types}}
*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}}
{{Immunosuppressant medication complications}}


==Clinical Features==
==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==
==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==
==Disposition==
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==See Also==
==See Also==
*[[Transplant complications]]
*[[Transplant complications]]
*[[Neutropenic fever]]
*[[Immunocompromised antibiotics]]
*[[In-Training Exam Review]]


==External Links==
==External Links==
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==References==
==References==
<references/>
<references/>
[[Category:Cardiology]]

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

Clinical Features

Rejection

  • Patients monitored with surveillance biopsies regularly
  • Spectrum of presentations, anywhere asymptomatic to in extremis

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

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

See Also

External Links

References

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