• Cardiac transplantation is a definitive therapy for end-stage heart disease with a worldwide 1 year survival of 85-90%, 5 year survival of ~60% and annual mortality rate of 4%.
• Infection and rejection are the leading causes of mortality in the first year.
• Most common symptoms of complication in heart transplant patients presenting to an emergency department: fever and shortness of breath.

Initial Evaluation:

• Thorough history and physical examination are necessary, with particular attention to timing (when the transplant was performed), reason for the transplant, current medications, other comorbidities and history of prior complications or rejection.

Investigations:

• Appropriate standard laboratory testing includes CBC with differential, renal function, liver function, electrolytes, magnesium, phosphorous, troponin and BNP.
• ECG and echocardiogram recommended for all patients with concerning symptoms.
• Have a low threshold for imaging, including a chest X-ray, CT chest and echocardiogram – especially if infection is suspected.

Early Complications:

• Occur in the immediate postoperative period, within days to weeks of the procedure.

Late complications:

• Occur late in the transplantation period, months to years after the procedure.

Clinical Pitfalls:

• Heart transplant recipients often present atypically without chest discomfort due to cardiac denervation; although reinnervation can occur within 5 years, it is usually incomplete.
• The baseline ECG for transplant recipients will differ from other patient populations; always compare to prior ECGs, if available.
  • Resting heart rate in transplant recipients ranges from 80-110 bpm, therefore, bradycardia in this patient population is defined as any heart rate < 80 bpm.
  • Other “new baseline” findings may include 2 distinct “p” waves on ECG, right bundle branch block and isolated premature atrial/ventricular complexes.
• Expect troponin and BNP to be elevated for several weeks to 3 months post-transplant, but a new elevation outside of this period can suggest graft rejection, ACS or other acute event.

• Important to take a multidisciplinary approach to care
  • Consult early with a cardiologist and/or transplant specialist, if available, to aid with recommendations and considerations.
• Pharmacotherapy considerations for heart transplant recipients:

1. Long B., Brady W.J., Gragossian A., Koyfman A., & Gottlieb M. (2021). A primer for managing cardiac transplant patients in the emergency department setting. American Journal of Emergency Medicine. 41,130-138. DOI: 1016/j.ajem.2020.12.071

   
   

2. Toronto Notes 2020: Comprehensive Medical Reference and Review. 36^th Toronto Notes for Medical Students, Inc; 2020. p. C38.

   
   

3. Ahmed T. & Jain A. (2021). Heart Transplantation. StatPearls. Retrieved April 5^th, 2022 

   
   

4. Long B. & Koyfman A. (2016). The emergency medicine approach to transplant complications. American Journal of Emergency Medicine. 34,2200-2208. DOI: 1016/j.ajem.2016.08.049

   
   

5. Walls R., Hockerberger R., & Gausche-Hill M. (eds) Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9^th ed. Philadelphia, PA: Elsevier; 2018.