Rosen & Barkin's 5-Minute Emergency Medicine Consult (129 page)

• If the patient is not on steroids, bacteremia risk is similar to that in the general population.
  
• High incidence of pneumonia
  
• Patients on steroids may not show meningeal signs
  

DIAGNOSIS

• Acute rejection
  
  • Nonspecific symptoms predominate because the heart is usually denervated
    
  • Fatigue
    
  • Dyspnea
    
  • Low-grade fever
    
  • Nausea
    
  • Vomiting
    
  • May be difficult to differentiate between infection and acute rejection
    
• Heart failure
  
  • Tachypnea
    
  • Rales
    
  • Hypoxia
    
  • S3
    
  • Murmur
    
  • Edema
    
• Allograft vasculopathy
  
  • As early as 3 months after transplantation (20–50% incidence by 5 yr)
    
  • Denervated hearts do not present with typical angina.
    
  • Insidious onset
    
    • Fatigue
      
    • Cough
      
    • Dyspnea
      
  • Acute onset
    
    • Heart failure
      
    • Sudden death
      
    • Infarction
      
• Infection (Opportunistic and conventional)
  
  • Fever
    
  • Skin lesions (zoster)
    
  • CMV
    
    • Mild (flu-like illness)
      
    • Fever
      
    • Nausea
      
    • Malaise
      
    • Pneumonitis (13–50% mortality)
      
    • Hepatitis
      
    • Gastroenteritis
      
    • Profound leukopenia
      

• Higher risk for post-transplant lymphoproliferative disease with Epstein–Barr virus seroconversion
  
• Like adults, at risk for allograft vasculopathy and its associated cardiac ischemia
  

• Assess for signs of rejection, cardiac dysfunction, and infarction:
  
  • ECG
    
  • Cardiac enzymes
    
  • Chest radiograph
    
  • Echocardiography
    
• Possible rejection requires biopsy, consult transplant team.
  

Normal fever workup + chest radiograph and ECG; if on steroids, perform LP

• Electrolytes:
  
  • Cyclosporine effects:
    
    • Increased blood urea nitrogen, creatinine
      
    • Hyperkalemia
      
    • Metabolic acidosis
      
    • Hyponatremia
      
• CBC:
  
  • Relative eosinophilia may indicate rejection over infection
    
• Blood and urine culture if febrile
  
• Lumbar puncture if seizures, altered mental status, or severe headache
  
• BNP (expect baseline elevation)
  
• CMV titers
  
• Urine antigen test
  
• Cyclosporine trough level
  

• ECG
  
  • Tachycardia
    
  • 20% decrease in total voltage (nonsensitive)
    
  • Note that normal rhythm for denervated heart is sinus 90–110 bpm
    
  • Depending on transplant surgical technique, may see 2 P-waves (native and donor heart):
    
  • Native P-waves do not correspond to quasi-random signal
    
• Chest radiograph
  
  • Cardiomegaly
    
  • Pulmonary edema
    
  • Pleural effusions
    
  • Compare with previous (healthy donor heart may appear large in small recipient)
    
• Echocardiography
  
  • Decreased mitral deceleration time
    
  • Initial diastolic dysfunction
    
  • Biventricular enlargement
    
  • Mitral/tricuspid regurgitation
    

• Rejection
  
• Infection
  
• Ischemia
  
• CMV
  
• Viral illness
  
• Malignancy
  
• Cyclosporine toxicity
  

TREATMENT

Adenosine should not be given to patients who have had a heart transplant as the effects may be prolonged and unpredictable.

• IV access
  
• Oxygen
  
• Monitor
  
• Intubation
  
• Defibrillation/pacing
  
• Vasopressors as required
  
• Arrhythmias
  
  • Advanced cardiac life support
    
  • Bradycardia does not respond to atropine; use isoproterenol
    

• Hemodynamically significant rejection
  
  • Methylprednisolone
    
  • May also require OKT3 or other anti–T-cell antibody therapy
    
• Infarct/vasculopathy
  
  • Aspirin
    
  • Heparin
    
  • Possible angioplasty
    
  • Likely need retransplantation
    
• CMV
  
  • Empiric IV ganciclovir
    
• HSV
  
  • Oral or IV acyclovir
    
• Gastroenteritis
  
  • Search for CMV infection with culture, serology
    
• Fever without a source
  
  • Consult infectious disease or transplantation team
    
• Headache
  
  • Threshold for CT scan and lumbar puncture should be low (meningitis, abscess)
    
• Serious illness/trauma/operation
  
  • Steroid burst
    
  • Limit NSAID use because risk for renal insufficiency from cyclosporine and tacrolimus.
    

• Acyclovir: 5–10 mg/kg IV q8h calculate dose on IBW; genital herpes: 400 mg PO TID × 7–10 days; varicella: 20 mg/kg up to 800 mg PO QID for 5 days
  
• Ceftriaxone: 50 mg/kg IV q12–24h
  
• Cyclosporine, CellCept, tacrolimus, sirolimus, Neoral, azathioprine, mycophenolate mofetil: Per transplantation team
  
• Ganciclovir: Insert IV; 5 mg/kg BID for 2–3 wk (adjust for renal function)
  
• Isoproterenol: 1–4 μg/min, titrate to effect; max. 10 μg/min
  
• Methylprednisolone: 1 g IV; peds: 10–20 mg/kg IV
  
• OKT3, daclizumab or other antibody therapy: Per transplant team
  

• Hemodynamically significant rejection
  
• Vasculopathy/ischemia
  
• New dysrhythmia
  
• Poorly controlled hypertension
  
• Congestive heart failure
  
• Dyspnea
  
• Hypoxia
  
• Temperature >38°C in adult or child on steroids
  
• Suspected CMV (unexplained fever, gastroenteritis, or interstitial pneumonitis)
  
• Not tolerating oral medicines
  
• Syncope
  

• Mild rejection
  
• Only in consultation with transplantation team
  
• Fever in nontoxic child:
  
  • Do not give children stress-dose steroids
    

• Abecassis M, Bridges ND, Clancy CJ, et al. Solid-organ transplantation in older adults: Current status and future research.
  Am J Transplant.
  2012;12:2608–2622.
  
• Chinnock R, Sherwin T, Robie S, et al. Emergency department presentation and management of pediatric heart transplant recipients.
  Pediatr Emerg Care
  . 1995;11(5):355–360.
  
• Cowan SW, Davison JM, Doria C, et al. Pregnancy after cardiac transplantation.
  Cardiol Clin
  . 2012;30:441–452.
  
• Massad MG. Current trends in heart transplantation.
  Cardiology
  . 2004;101:79–92.
  
• Mastrobattista JM, Gomez-Lobo V. Pregnancy after solid organ transplantation.
  Obstet Gynecol
  . 2008;112:919–932.
  

CODES

996.83 Complications of transplanted heart

BASICS

• Persistent hypotension and tissue hypoperfusion due to cardiac dysfunction in the presence of adequate intravascular volume and left ventricular (LV) filling pressure
  
• Most common cause of death in hospitalized patients with acute MI (AMI)
  
• Underlying mechanisms in AMI:
  
  • Pump failure:
    
    • ≥40% LV infarct
      
    • Infarct in pre-existing LV dysfunction
      
    • Reinfarction
      
  • Mechanical complications:
    
    • Acute mitral regurgitation
      
    • Ventricular septal defect
      
    • LV rupture
      
    • Pericardial tamponade
      
  • Right ventricular (RV) infarction
    
• 5–8% of patients with STEMI develop cardiogenic shock
  
• Role for a systemic inflammatory response syndrome via excess nitric oxide in the pathophysiology of cardiogenic shock
  
• Role of initial treatment with β-blockers, ACEI, and high-dose diuretics in cardiogenic shock development