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Hemodynamics versus biopsy findings during cardiac transplant rejection
S F Bolling1, J B Putnam, G D Abrams
1Section of Thoracic Surgery, University of Michigan School of Medicine, Ann Arbor.
Insights
Cyclosporine-based immunosuppression in heart transplant recipients did not show significant hemodynamic changes during rejection. Routine biopsies are crucial for diagnosing rejection, as hemodynamics do not reliably predict its severity.
Area of Science:
- Cardiology
- Transplantation Immunology
Background:
- Cardiac transplant rejection historically caused severe hemodynamic instability before cyclosporine.
- Hemodynamic changes during rejection in cyclosporine-treated patients remain poorly understood.
Purpose of the Study:
- To describe hemodynamic changes during cardiac allograft rejection in patients treated with cyclosporine-based immunosuppression.
- To correlate hemodynamic parameters with histologic rejection grades.
Main Methods:
- Prospective study of 89 adult orthotopic heart transplant recipients (July 1986-October 1989).
- Patients received triple-drug immunosuppression: steroids, cyclosporine, and azathioprine.
- Cardiac hemodynamics were measured and correlated with endomyocardial biopsy findings.
Main Results:
- No significant hemodynamic differences were observed across increasing rejection grades (0-4).
- Severe rejection (grade 4) was associated with congestive heart failure symptoms in 55% of patients.
- Symptomatic severe rejection patients had lower cardiac output (2.9 L/min) compared to asymptomatic ones (5.2 L/min).
- Overall hemodynamic decompensation did not correlate with rejection grade.
Conclusions:
- Hemodynamic monitoring alone is insufficient for detecting or assessing the severity of rejection in heart transplant patients on cyclosporine.
- Endomyocardial biopsy remains the gold standard for diagnosing rejection in asymptomatic heart transplant recipients.
Abstract:
Before the use of cyclosporine as the major component for immunosuppression after cardiac transplantation, rejection was accompanied by catastrophic hemodynamic decompensation. However, the hemodynamic changes that occur during rejection after cardiac transplantation in patients treated with cyclosporine have not been clearly described. Between July 1986 and October 1989, 89 adults underwent orthotopic heart transplantation at the University of Michigan Medical Center. All patients received triple-drug therapy immunosuppression consisting of steroids, cyclosporine, and azathioprine. Cardiac hemodynamics were measured and correlated with the histologic assessment of rejection. There have been ten deaths among these 89 patients for an overall survival of 89%. There were no deaths from rejection. One hundred fifty-three of the biopsy specimens were read as grade 0, 31 were grade 1, 75 were grade 2, 103 were grade 3, and 9 patients had grade 4 biopsy specimens. No hemodynamic differences were noted in patients with increasing grade of rejection. Five patients (5/9, 55%) with severe rejection (grade 4) had symptoms of congestive heart failure at the time of biopsy. These symptomatic grade 4 patients differed from asymptomatic grade 4 patients only in cardiac output (2.9 versus 5.2 L/min). Overall hemodynamic decompensation was not evident as rejection grade increased. Routine serial endomyocardial biopsies remain the procedure of choice in the diagnosis of rejection in the asymptomatic patient after cardiac transplantation as hemodynamics do not predict degree of rejection.