“The heart was made to be broken.” — Oscar Wilde
What Is Heart Rejection Like?
Following my second heart biopsy, I was diagnosed with moderate to high heart transplant rejection just three weeks after my heart transplant. It was anticipated to feel vulnerable during this period. Strangely, I didn’t notice any clear signs of rejection then, although I was already fatigued, breathless, and weak from the surgery.
I had been in St Vincent’s Hospital Heart-Lung Clinic earlier that day for the Routine Clinical Testing, including the heart biopsy.
I returned home to the Blue Mountains. Barely 30 minutes later the Transplant Team Doctor called and said I was in 2R to 3R rejection.
When You Have Heart Rejection
They needed me to return to SVHA with my hospital bag and present at ED as soon as possible.
The Emergency Department was completely full with nowhere to sit. Only 3 weeks post transplant, I was pretty fragile and my legs were not really working at all well. Despite being asked to come in I still needed to be processed through ED.
As usual I was triaged and admitted. However, there was a delay and much confusion around contacting the Transplant Doctor. Luckily, I had his number and was able to text him.
On the treating consultants instructions, I was moved to a single closed room (isolation room) in Emergency.
I stayed there for three days while the team administered 1000mg of (IV) Intravenous Methylprednisolone.
I was in the isolation room within ED as I was vulnerable to infection from the immunosuppression. The extra intravenous methylprednisolone made me increasingly susceptible to infection. The idea was to pretty much knock out the immune system so it would stop attacking and rejecting Wednesday, my new heart.
An Important Medication Tip
An important thing to mention here is, I was admitted after Pharmacy hours. I was so relieved, as was the treating Doctors that I had packed my medications. See the tips I give about hospitals and transplant medications in the post: Tips On Taking Medications After A Heart / Lung Transplant.
As always, I’ve done the research to gather the essential points about rejection from numerous resources for you. If you’re interested in delving deeper, I’ve curated a collection of valuable links at the end of this article. Let me take the lead in getting you started on this journey.
Heart Rejection: An Easy Guide
Heart transplant rejection is a crucial topic for anyone who has undergone a transplant or is considering one. It’s essential to understand the types of rejection, the symptoms, and the treatment options available to manage this condition effectively. Here’s a comprehensive guide to help you navigate this challenging aspect of heart transplantation.
Recognising Heart Transplant Rejection Symptoms
Heart transplant rejection occurs when the recipient’s immune system attacks the donor heart. This can often be asymptomatic, but common symptoms include:
- Shortness of breath
- Fatigue and tiredness
- Swollen ankles
- Increased weight
- Lightheadedness and dizziness
- Decreased exercise tolerance
- Heart palpitations
- Loss of appetite
Diagnosis typically involves an ECG, echocardiography, and endomyocardial biopsy to assess heart function and detect rejection .
Types of Rejection
1. Cellular Rejection
Mild to moderate cellular rejection (grades 1R to 2R) is the most common, especially within the first year post-transplant. The risk of rejection persists because the immune system continually works to protect the body, even against the new heart .
2. Antibody-Mediated Rejection (AMR)
AMR occurs when the immune system produces antibodies against the donor heart. Diagnosis involves a luminex assay to detect donor-specific antibodies (DSA). The severity of the antibodies is measured using Mean Fluorescent Intensity (MFI) .
Treatment for Heart Rejection
Managing Mild to Moderate Cellular Rejection
- High-dose intravenous methylprednisolone: Administered once daily (500-1000 mg) for three days.
- Oral prednisolone: Given twice daily, with doses gradually reduced over 1-2 weeks until the baseline dose is achieved.
- If steroid therapy is ineffective, alternatives such as antithymocyte globulin (ATG) or total body irradiation may be considered .
Treatment for Antibody-Mediated Rejection (AMR)
Moderate to severe AMR often requires intensive treatment and hospitalisation:
- Plasma Exchange: A vascular catheter is inserted into the neck vein to facilitate plasma exchange, removing antibodies from the blood. This process typically involves five treatments, each lasting about 2.5 hours.
- Rituximab Administration: After plasma exchange, Rituximab is administered to prevent further antibody production.
- Monitoring: A mid-course luminex test is performed to assess progress and effectiveness. Regular luminex testing is essential to monitor antibody levels over time .
Cardiac Allograft Vasculopathy (CAV)
CAV is a condition that can develop either soon after or long after a transplant, characterised by the narrowing of coronary arteries. This condition is graded from CAV 0 to CAV 3 based on the severity of vessel disease. Symptoms include ventricular dysfunction and abnormal wall motion on echocardiography, although many patients may not experience typical angina due to denervation of the transplanted heart .
Treatment and Management of CAV
- Regular Monitoring: Routine heart biopsies, echocardiography, angiography, and dobutamine stress echocardiography are essential for early detection and monitoring.
- Symptom Reporting: Promptly report any unusual symptoms or feelings of unwellness to your transplant clinic.
- Medication and Lifestyle Adjustments: Adjustments in immunosuppressive medications and lifestyle changes may be necessary to manage and slow the progression of CAV .
By continuing to do daily Home Health Testing and maintaining Crucial Testing with regular transplant clinic follow-ups, patients can manage rejection risks effectively and improve their long-term outcomes post-transplant.
As always you are invited to share your experiences and learnings via the form below.
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References
Advancing heart, lung, blood, and sleep research & innovation. (n.d.). NHLBI, NIH. Retrieved June 11, 2024, from https://www.nhlbi.nih.gov/
American Heart Association. (n.d.). Www.Heart.Org. Retrieved June 11, 2024, from https://www.heart.org/
American Journal of Transplantation. (n.d.). Wiley Online Library. Retrieved June 11, 2024, from https://onlinelibrary.wiley.com/journal/16006143
Clinical transplantation. (n.d.). Wiley Online Library. Retrieved June 11, 2024, from https://onlinelibrary.wiley.com/journal/13990012
Health, S. V. H. (n.d.). St Vincent’s Heart Health. St Vincent’s Heart Health. Retrieved June 11, 2024, from https://www.svhhearthealth.com.au/rehabilitation/after-heart-transplant
