Diagnosis of Cardiac Transplant Rejection Using Point-of-Care Ultrasound

Cardiac transplantation is a crucial intervention for end-stage heart failure, but complications such as acute cellular rejection and cardiac allograft vasculopathy continue to challenge patient outcomes. While endomyocardial biopsy is the gold standard for diagnosis, it is invasive, prompting the use of noninvasive methods like echocardiography. Point-of-care ultrasound (POCUS) has become increasingly accessible in the Emergency Department (ED), offering potential for early detection of transplant-related issues.

A 61-year-old female, 2 years post-cardiac transplant, presented to the ED with weakness, body aches, and shortness of breath. POCUS revealed new right ventricular (RV) dilation and strain, indicated by positive D-sign and increased tricuspid regurgitation. Prior labora results and recent right heart catheterization showed grade 2R acute cellular rejection, managed previously with prednisone. The new POCUS findings suggested a concern for cardiac transplant failure, and confirmatory biopsy identified recurrent acute cellular rejection. Despite treatment, the patient's condition worsened and she died. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POCUS should be a primary diagnostic tool for patients with a cardiac transplant history presenting with nonspecific symptoms. It can quickly identify RV dysfunction and diastolic abnormalities, which were crucial for the consideration of early diagnosis of transplant rejection as in this case. Familiarity with POCUS in this context enables emergency physicians to refine diagnostic approaches and improve management, ultimately enhancing patient care and outcomes.