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CardioNerds (Amit Goyal and Karan Desai) enjoy a picnic at Charm City\u2019s Inner Harbor with Dr. Manu Mysore, Dr. Shawn Samanta, and Dr. Rawan Amir from the University of Maryland division of Cardiology as they dive into important case discussion about a patient with of non-ischemic cardiomyopathy s/p orthotopic heart transplantation who presents with dyspnea due to cell mediated rejection. Dr. Gautam Ramani Medical Director of Clinical Advanced Heart Failure at the University of Maryland, provides the e-CPR segment.\n\n\n\nClaim free CME just for enjoying this episode! \n\n\n\n\n\nJump to: Patient summary - Case media - Case teaching - References \n\n\n\n\n\n\n\n\n\nCardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll\n\n\n\n\n\nCardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!\n\n\n\n\n\n\n\n\n\nPatient Summary\n\n\n\nA 58 year old woman with a history of non-ischemic cardiomyopathy s/p orthotopic heart transplantation in 2015 presented with worsening dyspnea upon exertion. Dyspnea in a post cardiac transplant brings forth a wide differential diagnosis spanning all the typical causes of dyspnea as well as causes more specific or common to the patient with a heart transplant. In this particular case, TTE showed newly reduced ejection fraction and valvular disease. Cell mediated rejection was considered highest on the differential and confirmed on endomyocardial biopsy. Given hemodynamic compromise with multiple foci of myocyte damage on biopsy, she was started on high dose steroids and anti-thymocyte globulin for treatment of rejection.\xa0 Early identification and management of cell mediated rejection is crucial to the survival of patients like ours. Final diagnosis: orthotopic heart transplantation rejection.\n\n\n\n\n\n\n\nCase Media - Orthotopic heart transplant rejection\n\n\n\n\n\n\nChest x-ray: Status post sternotomy. Patchy peripheral opacities in the bilateral lower lobes. Blunting of the costophrenic angles consistent with pleural effusion.\n\n\n\n\n\nSinus tachycardia, HR 111, RBBB, Sub millimeter STE in leads 1, aVL. STD in infero-posterior leads\n\n\n\n\n\n\n\nTTE: Short axis\n\n\n\n\n\nTTE: Long axis\n\n\n\n\n\nTTE: Apical 4 Chamber\n\n\n\n\n\n\n\n\nCoronary angiography: RCA\n\n\n\n\n\nCoronary angiography: LAD/LCx\n\n\n\n\n\n\n\n\n\n\n\n\n\nEpisode Education\n\n\n\n\n\n\n\n\n\nPearls \n\n\n\nNew onset heart failure in a post cardiac transplant patient should raise concern for acute cardiac allograft rejection, as well as all the usual culprits in nontransplant patients.Younger African American women and those with elevated HLA mismatches are key risk factors for cell mediated rejection.Treatment for cell-mediated (i.e., T-Cell mediated) rejection includes steroids and antithymocyte immunoglobulin and regimens are based on the severity ofclinical and histologic features.Though infrequent as an initial presentation of acute cellular rejection, new onset arrhythmias in a post cardiac transplant patient should raise concern for rejection as a possible etiology.\xa0Reversal of rejection should be verified with endomyocardial biopsy following treatment for rejection. The timing and frequency of biopsy will likely depend upon whether corticosteroids and/or antithymocyte therapy was utilized.\n\n\n\nNotes - Cell mediated rejection and more!\n\n\n\n1) What are some common complications of cardiac transplantation?\n\n\n\nCommon complications following cardiac transplantation can be divided into two major categories: graft-related complications and non-graft-related complications.\n\n\n\nGraft-related complications include:Early graft dysfunction (EGD) \u2013 reversible and irreversible injury related to organ procurement and reperfusion. Remember it is common for transplant patients to require inotropic and vasopressor support coming off cardiopulmonary bypass. Furthermore, LV diastolic dysfunction is also common after transplantation usually reflecting reversible ischemia or reperfusion injury and normally resolves over days to weeks,