Cardiovascular Medicine Q 1

Answer & Critique

Correct Answer: D

Educational Objective: Diagnose acute rejection in a cardiac transplant patient. 

Endomyocardial biopsy will most likely establish the diagnosis. For cardiac transplant recipients, the risk for rejection is highest within the first 6 months after transplantation and then within the first year. After that time period, the incidence of rejection is quite low. This posttransplant patient is presenting with signs and symptoms of acute heart failure, including abdominal discomfort, exertional dyspnea, and an S3. Additionally, the presence of cannon a waves suggests complete heart block, and the electrocardiogram is confirmatory, with P waves that march independent of the narrow QRS complex (arrows). All of these findings are consistent with acute rejection in a patient within the first year after cardiac transplantation, and the most appropriate test for diagnosis is endomyocardial biopsy. It is important to note that most patients with clinical rejection will not have any symptoms of heart failure; therefore, routine endomyocardial biopsies are performed within the first year after transplantation.

Abdominal CT would not establish the diagnosis. This patient's symptoms are most likely secondary to acute congestion; the patient's complete heart block and other cardiac findings should focus the clinician's attention on the heart. Abdominal CT should be performed only when the abdomen is thought to be the primary cause of the patient's symptoms. Coronary artery disease is a common long-term complication of cardiac transplantation, and by 5 years after transplantation, vasculopathy is present in almost 50% of patients.

Coronary artery disease would be more likely in a patient further removed from transplantation; therefore, coronary angiography would not establish the diagnosis. Echocardiography will confirm a decreased ejection fraction in this patient but cannot establish the diagnosis of rejection.

Key Point The risk for cardiac transplant rejection is highest within the first 6 months after transplantation and then within the first year; endomyocardial biopsy should be routinely performed within the first year after cardiac transplantation to diagnose rejection.

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