Cardiac Transplantation Complications
Basics
Description
Description
- Cardiac transplant recipients are a unique population with increased risk for cardiac ischemia, heart failure, as well as general risks as an immunocompromised host
- 1,900–2,300 cardiac transplants per year in the U.S.
- 1-yr survival 85–90%; 5-yr survival ∼75%
- Pediatric transplants increased 37% between 2004–2015
- Typical immunosuppressive therapy to control rejection is a “triple-drug” regimen often including steroids
- Evaluation for rejection:
- Frequent biopsies are used initially
- Echocardiography often used in children
- Complications occur most commonly in the first 6 wk after cardiac transplantation
Geriatric Considerations
- The proportions of elderly patients on the transplant list, and those receiving transplants are increasing
- Due to changes in immune system with age, elderly transplant recipients are at increased risk of life-threatening infections, and acute rejection
Pregnancy Considerations
- Pregnancy after cardiac transplant is becoming more common. Between 1988–2010, 63 women received either heart or heart–lung transplants. They have reported 108 pregnancies, all progressing to live births
- Most common complications include hypertension, pre-eclampsia, and rejection
- Physiologic changes that occur with pregnancy do not relate to increased rate of heart failure in transplant patients
- Special attention should be paid to these patients regarding rejection and infection given their immunosuppression
Etiology
Etiology
- Rejection:
- Hyperacute rejection:
- Occurs within minutes of transplantation
- Rare, due to ABO or other graft/host major incompatibility
- Aggressive and immediately fatal to graft
- Acute rejection:
- Lymphocyte infiltration and myocyte destruction
- Most common in the first 6 wk
- May occur at any time
- 23% incidence in first year post transplant
- Chronic rejection:
- Fibrosis and graft vascular disease
- Long-term complication
- Incompletely understood etiology
- No effective therapy
- Hyperacute rejection:
- Cardiac allograft vasculopathy:
- Analogous to accelerated coronary artery disease in native hearts
- Limits long-term survival, leading cause of mortality after 1 yr
- Immune-mediated atherosclerosis:
- Form of chronic rejection
- Infections:
- First month:
- Bacterial infections are the most common cause of mortality during this high-risk time period
- Pneumonia (Pseudomonas, Legionella, other gram-negative organisms)
- Mediastinitis
- Wound infection
- UTI
- First yr:
- Opportunistic and conventional infections
- Cytomegalovirus (CMV)
- Herpes simplex virus (HSV)
- Legionella
- Fungal infections
- Pneumocystis carinii
- First month:
- Medication toxicity
- Cyclosporine, neoral (second-generation cyclosporine), tacrolimus:
- Nephrotoxicity (30% incidence)
- Hepatotoxicity
- Neurotoxicity
- Hyperlipidemia, diabetogenic
- Azathioprine, mycophenolate mofetil:
- Bone marrow suppression
- Leukopenia
- Sirolimus:
- Hyperlipidemia
- Wound healing
- Steroids:
- Osteoporosis
- Cushing disease
- Cyclosporine, neoral (second-generation cyclosporine), tacrolimus:
- Neoplasms:
- Secondary to immunosuppression
- 10–100 times more common vs. general population
- Skin and lip cancer
- Lymphomas
- Kaposi sarcoma
- Solid organ neoplasms
Pediatric Considerations
- If the patient is not on steroids, bacteremia risk is similar to that in the general population
- High incidence of pneumonia
- Patients on steroids may not show meningeal signs
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Citation
Schaider, Jeffrey J., et al., editors. "Cardiac Transplantation Complications." 5-Minute Emergency Consult, 6th ed., Lippincott Williams & Wilkins, 2020. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307463/all/Cardiac_Transplantation_Complications.
Cardiac Transplantation Complications. In: Schaider JJJ, Barkin RMR, Hayden SRS, et al, eds. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307463/all/Cardiac_Transplantation_Complications. Accessed December 11, 2024.
Cardiac Transplantation Complications. (2020). In Schaider, J. J., Barkin, R. M., Hayden, S. R., Wolfe, R. E., Barkin, A. Z., Shayne, P., & Rosen, P. (Eds.), 5-Minute Emergency Consult (6th ed.). Lippincott Williams & Wilkins. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307463/all/Cardiac_Transplantation_Complications
Cardiac Transplantation Complications [Internet]. In: Schaider JJJ, Barkin RMR, Hayden SRS, Wolfe RER, Barkin AZA, Shayne PP, Rosen PP, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. [cited 2024 December 11]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307463/all/Cardiac_Transplantation_Complications.
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