Approach to Heart Transplant Complications
- Cardiac transplantation is a definitive therapy for end-stage heart disease with a worldwide 1 year survival of 85-90%, 5 year survival of ~60% and annual mortality rate of 4%.
- Infection and rejection are the leading causes of mortality in the first year.
- Most common symptoms of complication in heart transplant patients presenting to an emergency department: fever and shortness of breath.
- Thorough history and physical examination are necessary, with particular attention to timing (when the transplant was performed), reason for the transplant, current medications, other comorbidities and history of prior complications or rejection.
- Appropriate standard laboratory testing includes CBC with differential, renal function, liver function, electrolytes, magnesium, phosphorous, troponin and BNP.
- ECG and echocardiogram recommended for all patients with concerning symptoms.
- Have a low threshold for imaging, including a chest X-ray, CT chest and echocardiogram – especially if infection is suspected.
- Occur in the immediate postoperative period, within days to weeks of the procedure.
- Occur late in the transplantation period, months to years after the procedure.
- Heart transplant recipients often present atypically without chest discomfort due to cardiac denervation; although reinnervation can occur within 5 years, it is usually incomplete.
- The baseline ECG for transplant recipients will differ from other patient populations; always compare to prior ECGs, if available.
- Resting heart rate in transplant recipients ranges from 80-110 bpm, therefore, bradycardia in this patient population is defined as any heart rate < 80 bpm.
- Other “new baseline” findings may include 2 distinct “p” waves on ECG, right bundle branch block and isolated premature atrial/ventricular complexes.
- Expect troponin and BNP to be elevated for several weeks to 3 months post-transplant, but a new elevation outside of this period can suggest graft rejection, ACS or other acute event.
- Important to take a multidisciplinary approach to care
- Consult early with a cardiologist and/or transplant specialist, if available, to aid with recommendations and considerations.
- Pharmacotherapy considerations for heart transplant recipients:
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
These recommendations are based on observational data and expert opinion.
Long B., Brady W.J., Gragossian A., Koyfman A., & Gottlieb M. (2021). A primer for managing cardiac transplant patients in the emergency department setting. American Journal of Emergency Medicine. 41,130-138. DOI: 1016/j.ajem.2020.12.071
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated May 06, 2022
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