Heart Transplant Rejection

What is heart transplant rejection?

Your immune system’s job is to seek out and destroy foreign substances in the body. It destroys bacteria and viruses to help keep you healthy. Normally, this is a good thing, but sometimes the immune system’s response can lead to problems.

During a heart transplant, a surgeon removes your badly working heart and replaces it with a healthy heart from a donor. The immune system sees the new heart as a foreign object and can start to attack it. This is known as transplant rejection.

When you have a heart transplant, you will need to take certain medicines for the rest of your life. These help to prevent rejection of the new heart by your immune system. Transplant rejection is very common. It’s common even in people who take all their medicines as prescribed.

The most common type of heart transplant rejection is called acute cellular rejection. This happens when your T-cells (part of your immune system) attack the cells of your new heart. It happens most often in the first 3 to 6 months after transplant.

Humoral rejection is a less common type. It’s also known as acute antibody rejection. It can develop during the first month after transplantation. Or it can happen as late as months to years after transplant. With humoral rejection, antibodies injure the blood vessels in your body, including your coronary arteries. This can cause problems with blood flow to the heart.

Heart transplant rejection can also be chronic. Coronary artery vasculopathy is a form of chronic rejection. It affects the coronary arteries. These supply the heart muscle with oxygen and nutrients. In coronary artery vasculopathy, the inner lining of the blood vessel thickens. This can lead to less blood going to the heart muscle. Your healthcare provider may prescribe certain medicines to prevent and treat this type of rejection.

What causes heart transplant rejection?

Heart transplant rejection can happen in a normally functioning immune system. Failing to take anti-rejection medicines as prescribed can cause transplant rejection. But many people who take their medicines as prescribed still have rejection. No one knows for sure why this happens.

Who is at risk for heart transplant rejection?

Certain things increase the chances of both acute and chronic heart transplant rejection. One of the most important factors is a genetic mismatch between the heart donor and heart recipient. Younger heart recipients are also at greater risk for both kinds of rejection.

Other factors that specifically increase the chances of acute transplant rejection include:

  • Time after transplantation. Rejection risk is highest several weeks after the transplant and then starts to decrease
  • Female heart recipient or female heart donor
  • African-American heart recipient

Some factors that specifically increase the chances of chronic rejection include:

  • Elevated cholesterol levels
  • Cytomegalovirus infection
  • Older heart donor
  • Male donor
  • Younger recipient
  • History of acute heart rejection
  • Coronary heart disease in the donor or the recipient
  • Insulin resistance

What are the symptoms of heart transplant rejection?

Some of the symptoms of acute heart transplant rejection include:

  • Feeling tired or weak
  • Fever or chills
  • Shortness of breath
  • Fast or irregular heartbeat
  • Drop in blood pressure
  • Swelling of your feet, hands, or ankles
  • Sudden weight gain
  • Flu-like aches and pains
  • Reduced amounts of urine
  • Dizziness or fainting
  • Nausea or loss of appetite

It is common for rejection to happen without any symptoms at all. Because of very intense rules for screening after transplant, many cases are found before symptoms develop. This is one reason why it is so important to make all your follow-up visits.

Chronic heart transplant rejection often has no symptoms at all. The first symptom might be a heart attack.

How is heart transplant rejection diagnosed?

Diagnosis starts with a recent health history, physical exam, and blood tests. Often a healthcare provider will diagnose acute rejection with a heart biopsy. You may have multiple routine biopsies after a heart transplant. This helps them to watch for rejection. These biopsies often show signs of transplant rejection before you have any symptoms. Finding a rejection early increases the chances it can be treated.

Sometimes healthcare providers spot acute rejection with a blood test. This test checks for certain genes tied to transplant rejection. Your healthcare provider might use other standard tests to evaluate your heart function. Some examples include:

  • Electrocardiogram (ECG) to monitor the heart rhythm
  • Echocardiogram to evaluate heart function

Other tests are sometimes needed for the diagnosis of chronic rejection. These tests help provide a better look at the blood vessels. These may include:

  • Coronary angiography
  • Intravascular ultrasound
  • Cardiac stress testing

How is heart transplant rejection treated?

Treatment depends on a number of factors. These include the severity of the rejection, symptoms, current medicines, and the type of rejection. Some options for treating acute cellular transplant rejection include:

  • Increasing the dose or frequency of a current anti-rejection medicine
  • Changing to a different anti-rejection medicine
  • Adding additional medicines that suppress the immune system, such as prednisone
  • For more severe cases, you may need treatment with medicines given through your vein

Plasmapheresis is the main treatment for rejection mediated by antibodies. This is called acute humoral rejection. Plasmapheresis filters the blood and removes the harmful antibodies.

Increasing the dose of anti-rejection medicines is another way to treat chronic rejection. If the damage is more severe, with significant blockages in the coronary arteries, you may need angioplasty or open heart surgery. These procedures help provide greater flow to the coronary arteries. Rarely, chronic rejection requires another transplant. Living a heart healthy lifestyle can decrease the risk of developing chronic rejection in the form of coronary artery vasculopathy.

After you get treatment for rejection, you will need to be closely monitored. You might need follow-up tests to see how you respond.

Medicines used to prevent rejection do suppress the immune system. This increases the risk for infection. Your risk of heart failure also increases with rejection. Due to these possible complications, your healthcare provider may:

  • Give you antibiotic and antiviral medicines. These are needed if you are using certain anti-rejection medicines. They don’t treat the rejection itself, but they may help to prevent infection.
  • Give you medicines to treat heart failure, like beta-blockers. These may be needed if the rejection is severely affecting your new heart.

What are the complications of heart transplant rejection?

In rare cases, heart transplant rejection can cause complications such as:

  • Failure of the new donor heart
  • Abnormal heart rhythms (some of which can cause sudden death)
  • Heart attack

What can I do to prevent heart transplant rejection?

You can reduce your chances of having heart transplant rejection and complications from rejection. Here are some things you can do:

  • Make sure to take all your medicines exactly as prescribed.
  • Have an adequate supply of your medicines on hand.
  • Check your weight, blood pressure, and temperature as ordered by your healthcare provider.
  • Keep all scheduled healthcare provider appointments.
  • Have your lab work and other tests done on time.
  • Contact your transplant team right away if you have any signs of transplant rejection.
  • Follow up on any tests with your transplant team.
  • Live a heart healthy lifestyle, including regular exercise and a healthy diet.
  • Avoid tobacco products and excessive alcohol use.

Living with a heart transplant

Your healthcare provider may have further instructions about how to manage your condition. This might include:

  • Living a healthy lifestyle. Eat a heart-healthy diet and get enough exercise. Avoid tobacco products, illegal drugs, and excess alcohol. Maintain a healthy weight.
  • Taking other medicines for your heart. These might include medicines to reduce cholesterol, lower your blood pressure, or help manage your blood glucose. Some of these medicines might help lower the chances of chronic rejection as well.

When should I call my healthcare provider?

Call your transplant team right away if you have any signs of rejection. Also call if you generally do not feel well. Do not wait until your next scheduled appointment.

Key points

  • Heart transplant rejection is very common after heart transplant surgery. Rejection can be acute or chronic. The immune system attacks the donated heart, leading to symptoms.
  • Follow all of your healthcare provider’s instructions carefully. This will help decrease your chances of rejection. It will also make it easier for your healthcare provider to detect rejection early, when he or she can treat it more easily.
  • Know what symptoms might be signs of heart transplant rejection. Tell your transplant team about any symptoms right away.
  • You will need close monitoring to check for signs of rejection.
  • The risks of acute rejection lessen with time, but rejection is always a risk. You will always need anti-rejection medicines to help prevent transplant rejection.
  • Treatment of transplant rejection often involves increasing the dose of medicines you are taking. Your healthcare provider may add new medicines.
  • Maintaining a healthy lifestyle can help keep your heart healthy.
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