Challenges of Treating Late Onset Severe Antibody Mediated Rejection Post Orthotopic Heart Transplant

IntroductionOutcomes of severe antibody mediated rejection (AMR) post orthotopic heart transplant (OHT) are often poor & management a challenge.Case ReportA 50-year-old multiparous female with stable donor specific antibodies (DSAs) presented cardiogenic shock (CS) left ventricular (LV) dysfunction 4 years OHT. Maintenance immunosuppressants (IS) included tacrolimus, mycophenolate prednisolone good adherence. Urgent endomyocardial biopsy (EMB), coronary angiogram right catheterisation were performed. Progression to SCAI Stage D necessitated venoarterial extracorporeal membrane oxygenation (VA ECMO) within 24 hrs. Based on clinical presentation, the patient was treated methylprednisolone, intravenous immunoglobulin (IVIG) IV thymoglobulin alongside hemodynamic other organ support (dialysis, ventilation). EMB confirmed pAMR3 fulfilling criteria for AMR together CS raised DSAs. Within days patient's cardiac output improved allowing removal VA ECMO. Following MDT consensus given persistent graft DSAs an regimen plasmapheresis, IVIG rituximab administered resulting in significant improvement LV function A serious consequence high dose IS CMV reactivation (CMV peak 18,000 copies/ml). Successful treatment ganciclovir caused leukopenia requiring cessation. Fortunately our survived discharge day 152 admission recovery excellent functional capacity. Ongoing remains challenge due CAV balancing risks associated recurrence.SummaryThis case highlights importance urgent evaluation including EMB, targeted anti-rejection therapy patients OHT allograft dysfunction. It exemplifies challenges when treating illustrating collaborative team approach successful outcomes. Outcomes challenge. recurrence. This Tabled 1RHC values over course DSA trend timeTime 1 (Admission)Time 2 (Hour 17)Time 3 (Day 12)Time 47)Right Atrial Pressure107168Pulmonary Artery Pressure (S/D/M)32/13/1930/6/1845/25/3229/18/23Pulmonary SaO261.5%30%49%60.5%Cardiac Output(L/min)4.62.14.45.9Cardiac Index (L/min/m2)2.41.13.2DSA (HLA Subtypes):B60DQ8DQa3DRw53Pre-transplant (MFI)2540128112812285 Months Pre-Admission (MFI)26950750758Admission (MFI)436811316113165266Day 12 (MFI)1093657465742847Day 19 MFI)1575940994092952Day 175 (MFI)15818631863786 Open table new tab