Hemodyanamic compromise rejection (HCR) has been reported to be between 5 and 20% in the cardiac transplantation population. There has been controversy as to whether this form of rejection leads to a higher incidence of cardiac allograft vasculopathy (CAV) and nonfatal major adverse cardiac events (nf-MACE, defined as acute myocardial infarction, congestive heart failure, percutaneous cardiac intervention, need for implantable cardiac defibrilator, cerebral vascular accident, peripheral vascular disease). In our program, HCR is defined as heart failure symptoms associated with left ventricular ejection fraction ≤ 40%, cardiac index ≤ 2.0 L/min/m2, and the need for inotropic support. Between January 1994 and December 2003, 487 heart transplants were performed at our institution. There were 86 episodes of HCR, 23 occurring less than 30 days (early HCR) and 63 occurring greater than 30 days (late HCR) after heart transplantation. Compared to those patients without HCR (control group), 5-year survival was significantly less in those patients with early HCR (early HCR 47.8% vs control 71.3%, p = .008). The incidence of nf-MACE and CAV was without difference between these two groups. However, more patients in the early HCR group died and did not have the opportunity to develop nf-MACE and CAV. For patients with late HCR, 5-year survival and nf-MACE was comparable compared to the control group. However, there was increased development of CAV at 5 years (33.3% vs 21.7% for control, p = .049). For early and late HCR combined, there was significantly more nf-MACE compared to the control group (12.8% vs 5.1%, p = .011).
Conclusion HCR less than 30 days of transplant confers poor 5-year survival, and late HCR is associated with greater development of CAV at 5 years. Overall, HCR is associated with the development of nf-MACE. Modification of subsequent maintenance of immunosuppresion and/or careful monitoring need to be pursued in these patients in order to improve outcome.
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