Chest pain in a heart transplant recipient: A case report

Heart transplantation is recommended for the treatment of patients with refractory heart failure. Chest pain after heart transplantation is usually considered noncardiac owing to the denervated heart. However, data from case reports on tacrolimus-induced achalasia after heart transplantation are limited. We aimed to present a case of tacrolimus-induced achalasia that developed after heart transplantation, which was successfully relieved by laparoscopic Heller myotomy.

A 67-year-old man with a history of Type 2 diabetes mellitus, hyperlipidemia, and dilated cardiomyopathy had congestive heart failure following orthotopic heart transplantation with tacrolimus treatment 12 years ago. At the 10-year follow-up after the heart transplantation, the patient presented with persistent cough, dysphagia, heartburn, and retrosternal chest pain lasting for 2 wk. Upper endoscopy revealed no specific findings. Two years later, the patient experienced the same symptoms, including chest pain lasting for 4 wk. Esophagogram and manometry confirmed the presence of achalasia. Previous reports showed that discontinuing calcineurin inhibitor (CNI) treatment and endoscopic botulinum toxin injection could treat CNI-induced achalasia. Owing to the risk of rejection of the transplanted heart and considering the temporary benefits of botulinum toxin injection in achalasia, the patient underwent laparoscopic Heller myotomy. Dysphagia was relieved without complications. Eight months later, he had no signs of recurrence of the achalasia.

In transplant patients with chest pain and gastrointestinal symptoms, CNI-induced achalasia may be one of the differential diagnoses. Esophagogram/manometry is useful for diagnosis.