Clinical Case of Cellular rejection after Heart Transplantation

  • S. V. Fedkiv National Amosov Institute of Cardiovascular Surgery, Kyiv, Ukraine; Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine
  • S. V. Potashev National Amosov Institute of Cardiovascular Surgery, Kyiv, Ukraine
  • K. V. Rudenko National Amosov Institute of Cardiovascular Surgery, Kyiv, Ukraine
  • V. P. Zakharova National Amosov Institute of Cardiovascular Surgery, Kyiv, Ukraine
  • E. A. Chizhevskaya National Amosov Institute of Cardiovascular Surgery, Kyiv, Ukraine
Keywords: cardiac transplantation, acute cellular rejection, endomyocardial biopsy, echocardiography, heart MRI

Abstract

Transplant rejection is one of the most important complications after organ transplantation. It was the main obstacle during the first years after heart transplantation implementation. Wide clinical spread of heart transplantation induced rapid development and implementation of many new immunosuppressants. Further success in this field was due to the use of immunosuppressant combinations which allowed to significantly decrease the incidence of cellular heart transplant rejection. Apoptosis has been implicated in the pathophysiology of various forms of heart disorders. Acute cellular rejection (ACR) causes post-heart transplantation morbidity; invasive techniques are needed for its diagnosis, however, these are not generally available. Endomyocardial biopsy (EMB) is a routine procedure aimed to monitor transplanted heart morphology and outcome. ACR occurs most commonly and is characterized by the presence of inflammatory cells in the myocardium, with diagnosis being significantly dependent from pathohistological examination results. The therapy still remains mainly empirical. ACR has been described precisely, and the advent of immunosuppressants significantly lowered its frequency. This paper describes such a clinical case in one of our patients with the review of contemporary criteria for diagnosis as well as treatment options focusing at existing limitations and need for further studies and innovations. Clinical efforts in managing the patients after heart transplantation include three basic goals: prevention of rejection, prevention of infectious complications and minimization of potential side effects of immunosuppressive therapy. Today the diagnosis of rejection strongly depends on pathomorphologic findings of EMB. However, up-to-date methods of cardiovascular visualization, namely EchoCG with TDI and STE and cardiovascular MRI, are also a valuable instrument for diagnosis. These investigations allow for high suspicion of heart transplant rejection earlier than EMB or in case it is not available, which was demonstrated in the described clinical case. For now management of such patients remains mainly empirical, and we hope that advances in molecular biology will help us to improve our capabilities in managing such patients.

References

  1. Lund LH, Edwards LB, Kucheryavaya AY, Benden Ch, Christie JD, Dipchand AI, et al. The registry of the International Society for Heart and Lung Transplantation: Thirty-first official adult heart transplant report – 2014; Focus Theme: Retransplantation. J Heart Lung Transplant. 2014;33:996–1008. https://doi.org/10.1016/j.healun.2014.08.003
  2. Li L, Duan X, Wang H, Wang Q. Acute cellular rejection and antibody-mediated rejection in endomyocardial biopsy after heart transplantation: a retrospective study from a single medical center. Int J Clin Exp Pathol. 2017;10(4):4772–9.
  3. Stehlik J, Edwards LB, Kucheryavaya AY, Benden C, Christie JD, Dipchand AI, Dobbels F, Kirk R, Rahmel AO, Hertz MI; International Society of Heart and Lung Transplantation. The registry of the international society for heart and lung transplantation: 29th official adult heart transplant report – 2012. J Heart Lung Transplant. 2012;31:1052–64. https://doi.org/10.1016/j.healun.2012.08.002
  4. Strecker T, Rosch J, Weyand M, Agaimy A. Endomyocardial biopsy for monitoring heart transplant patients: 11-years-experience at a german heart center. Int J Clin Exp Pathol. 2013;6:55–65.
  5. Marboe CC, Billingham M, Eisen H, Deng MC, Baron H, Mehra M, et al. Nodular endocardial infiltrates (quilty lesions) cause significant variability in diagnosis of ISHLT grade 2 and 3A rejection in cardiac allograft recipients. Journal of Heart and Lung Transplantation. 2015; 24(7):S219–S226. https://doi.org/10.1016/j.healun.2005.04.001
  6. Kim IC, Youn JC, Kobashigawa JA. The Past, Present and Future of Heart Transplantation. Korean Circ J. 2018 Jul;48(7):565–90. https://doi.org/10.4070/kcj.2018.0189
  7. Kim IC, Oh J, Lee CJ, Kim JY, Youn YN, Kang SM. Bioptome perforation at superior vena cava anastomosis site in transplanted heart. Korean Circ J. 2017;47:538–9. https://doi.org/10.4070/kcj.2017.0015
  8. Kittleson MM, Patel JK, Kobashigawa JA. Chapter 72: cardiac transplantation. In: Fuster V, Harrington RA, Narula J, Eapen ZJ, editors. Hurst’s the Heart. 14th ed. New York (NY): McGraw-Hill; 2017.
  9. Weber BN, Kobashigawa JA, Givertz MM. Evolving areas in heart transplantation. JACC Heart Fail. 2017;5:869–78. https://doi.org/10.1016/j.jchf.2017.10.009
  10. Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S, et al. The International Society of Heart and Lung Transplantation guidelines for the care of heart transplant recipients. J Heart Lung Transplant. 2010;29:914–56. https://doi.org/10.1016/j.healun.2010.05.034
  11. Kobashigawa J, editor. Clinical Guide to Heart Transplantation. Los Angeles (CA): Springer; 2017. https://doi.org/10.1007/978-3-319-43773-6
Published
2019-09-16
How to Cite
Fedkiv, S. V., Potashev, S. V., Rudenko, K. V., Zakharova, V. P., & Chizhevskaya, E. A. (2019). Clinical Case of Cellular rejection after Heart Transplantation. Ukrainian Journal of Cardiovascular Surgery, (3 (36), 82-89. Retrieved from https://cvs.org.ua/index.php/ujcvs/article/view/307
Issue
Ukrainian Journal of Cardiovascular Surgery No 3 (36) 2019
Section
CASE REPORT