Miller Charles, Arkun Knarik, DeNofrio David, Sabe Marwa
Division of Cardiology, Tufts Medical Center, 800 Washington Street, Boston, MA, USA.
Department of Pathology, Tufts Medical Center, Boston, MA, USA.
Eur Heart J Case Rep. 2019 Sep 1;3(3). doi: 10.1093/ehjcr/ytz100.
Very late antibody-mediated rejection (AMR) in heart transplant patients (over 10 years post-transplant) is very rare. It is associated with high mortality, graft dysfunction, and fulminant coronary artery vasculopathy (CAV) and should remain in the differential for patients presenting with late graft dysfunction.
A 57-year-old woman 16 years of post-heart transplant with a previously unremarkable post-transplant course including protocol driven biopsies showing no rejection and a recent unremarkable screening nuclear stress test presented to our institution with clinical heart failure. Echocardiogram revealed graft dysfunction and endomyocardial biopsy showed no signs of cellular rejection, but evidence of AMR. The patient was treated with steroid and immunotherapy with clinical improvement but suffered several infectious complications and renal dysfunction requiring haemodialysis related to her immunotherapy treatment. Despite aggressive AMR management, donor-specific antibodies and symptoms persisted and CAV progressed.
This case illustrates the poor diagnostic yield of non-invasive testing for AMR, and highlights importance to clinicians of considering AMR even if the patient over 10 years post-transplant when the diagnosis is rare.
心脏移植患者中极晚期抗体介导的排斥反应（AMR）（移植后超过10年）非常罕见。它与高死亡率、移植物功能障碍和暴发性冠状动脉血管病变（CAV）相关，对于出现晚期移植物功能障碍的患者，应将其纳入鉴别诊断范围。
一名57岁女性，心脏移植术后16年，此前移植过程无异常，包括按方案进行的活检未显示排斥反应，近期的筛查核素负荷试验也无异常，因临床心力衰竭就诊于我院。超声心动图显示移植物功能障碍，心内膜心肌活检未显示细胞排斥迹象，但有AMR证据。患者接受了类固醇和免疫治疗，临床症状有所改善，但出现了几种感染并发症以及与免疫治疗相关的需要血液透析的肾功能障碍。尽管积极管理AMR，但供体特异性抗体和症状持续存在，CAV进展。
该病例说明了AMR无创检测的诊断阳性率较低，并强调了即使对于移植后超过10年且诊断罕见的患者，临床医生考虑AMR的重要性。
