Cardiac Retransplantation: A Viable Option One, Two and Three Times | Patient Case Quiz

May 28, 2015   |  Nahikari Salterain Gonzalez, MD; Cristian Delgado-Domínguez, MD; Luis Daniel Mejias Sosa, MD; Gregorio Rabago, MD
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A 51-year-old male with familial dilated cardiomyopathy had his first heart transplant in 1990 and required a second heart transplant in 2003 because of graft vascular disease.

Since that the second transplant, follow-up was uneventful. Immunosuppression with triple therapy is established (cyclosporine A, mycophenolate mofetil, and steroids). Secondary to the calcineurin inhibitor treatment, he developed renal failure requiring a switch from cyclosporine to m-Tor inhibitors (baseline creatinine level 1.8 mg/dl and MDRD 42 mL/min/1.73 m2). In 2010, he had his first admission for heart failure (HF); suspecting cardiac rejection, a biopsy was performed confirming a Grade 1 acute rejection (Figures 1 and 2), which was treated conservatively (high-dose intravenous methylprednisolone).

Figure 1

Figure 1
Left: Hematoxylin and eosin stain showing a significant interstitial infiltration of collagenous fibers betwenn myocites. Right: Masson trichrome stain confirming high density of collagenous fibers.

Figure 2

Figure 2
Left: Hematoxylin and eosin stain showing a coronary vessel wall thickening. Right: Masson trichrome stain of a coronary vessel.

In one of his follow-up echocardiograms a diffuse thickening of both ventricles was observed (Figure 3) with normal left ventricular ejection fraction and a dilated right ventricle with severely impaired function (TAPSE 4 mm). The filling pattern was restrictive with high filling pressures (E/E' 15). His New York Heart Association (NYHA) functional class declined to III-IV; he required several admissions between 2010 and 2012, and was treated with inotropic drugs and high-dose diuretics (Figure 4). Due to a lack of exact diagnosis, his physicians decided to perform a right catheterization (mPAP 34 mm Hg, PCWP 18 mmHg, CO 3.7 L/min, and PVR 4.4 Wood units) and repeat the biopsy ruling out rejection. The last blood test showed 9.2 g/dL Hb (29.6% Hto), stable renal function and high percentage of anti-human leucocyte antigen (HLA) antibodies (by luminex) (Figures 5 and 6).

Figure 3

Figure 3
Diffuse thickening of both ventricles (left ventricle hypertrophy mainly) in two-chamber, four-chamber, and short-axis views.

Figure 4

Figure 4
Postero-anterior and lateral chest X-ray images of the last admission. A bilateral massive pleural effusion can be seen.

Figure 5

Figure 5
Anti-HLA Type I Antibodies

Figure 6

Figure 6
Anti-HLA Type II Antibodies

Which of the following statements describes the best management in this situation?

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