[The follow-up of the heart transplant patient]

The authors' purpose is to describe the follow-up of heart-transplant patients after they are released from the heart transplant center and entrusted to their personal physicians and/or to peripheral hospital centers. Three principle periods have been identified. FIRST THREE MONTHS: This period is characterized by a high risk of morbidity and mortality due to the various hemodynamic, immunologic and infectious problems present after transplantation. These problems require careful clinical and laboratory monitoring for diagnostic identification and correct treatment. Because of the complexity of procedures such as endomyocardial biopsy, infusion therapy and incidental pacemaker installation, the patient must be attended to by the heart transplant center. FROM THE THIRD MONTH TO THE FIRST YEAR: This corresponds to the period in which the subject is definitively released from the hospital to his or her own home. The aggressive immunologic action slows down and the first iatrogenic complications arise. Without neglecting the risk of rejection, it is also very important to monitor infectious complications, especially the ones caused by bacterial and/or mycotic agents even after minor incidents. This is particularly true when the patient resumes his own daily and work activity, which must nevertheless be encouraged and aided. The follow-up can be done by peripheral hospital centers, as long as the patients stay in close contact with the transplant center. AFTER THE FIRST YEAR: A satisfactory balance with the cellular immunologic action is achieved and the graft begins to suffer from the slow action of circulating antibodies, whose principle target is the coronary endothelium. Coronary artery disease begins to progress with multiple myocardial ischemic consequences: this represents the chronic rejection phenomenology. There is a further complication in the follow-up of these patients, i.e. the high incidence of neoplasms, particularly lymphomas and skin tumors supported by the immunosuppressive treatment. Together, coronary artery disease and neoplasms represent the most important factors in late mortality (34%).