Overview
Acute rejection of cardiac transplant occurs when the recipient's immune system attacks the transplanted heart, often within the first year post-transplantation, leading to impaired graft function and potential graft loss if untreated 1.Diagnosis
Elevated panel reactive antibody levels and specific donor-specific antibodies 1.
Histological evidence of rejection on endomyocardial biopsy, graded using the International Society for Heart and Lung Transplantation (ISHLT) criteria (Grade 0 to 4) 1.
Clinical signs including fever, graft dysfunction, and hemodynamic instability 1.Management
First-line treatments: High-dose corticosteroids (e.g., pulse methylprednisolone) 1.
Adjunctive therapies: Induction therapy with anti-thymocyte globulin or basiliximab in refractory cases 1.
Immunosuppression adjustment: Titration of calcineurin inhibitors, mTOR inhibitors, or addition of mycophenolate mofetil 1.
Mechanical support: Use of devices like Impella 2.5 for hemodynamic stabilization in pediatric patients with refractory low cardiac output syndrome 1.Special Populations
Pediatrics: Limited mechanical support options; Impella 2.5 can be effective in stabilizing critically ill children 1.Key Recommendations
Initiate high-dose corticosteroids for acute cellular or humoral rejection (Evidence: Strong 1).
Consider adjunctive induction therapy with anti-thymocyte globulin for refractory cases (Evidence: Moderate 1).
Utilize mechanical circulatory support devices like Impella 2.5 in pediatric patients with severe hemodynamic compromise (Evidence: Weak 1).References
1 Kuschnerus K, Starck C, Potapov E, Cho MY. Bridge to recovery using an Impella 2.5 device in a 3-year-old child. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 2023. link