Acute Rejection Following Cardiac Transplantation

Nine patients have undergone cardiac transplantation at Stanford University Hospital. Three of these showed no clinical evidence of rejection and had essentially normal physical and phonocardiographic findings. There were eight distinct early rejection episodes in the other six patients. Early rejection was accompanied by decreasing QRS voltage, an early diastolic gallop, and frequently a rightward shift of the mean electrical axis of the heart. If not treated, this progressed to severe heart failure with a right ventricular heave, biventricular gallop, marked elevation of venous pressure with rapid y descent and severe dyspnea without orthopnea. Ultrasound measurements show increasing posterior wall thickness and overall heart diameter during the rejection episode. With aggressive therapy, all of these signs usually resolve rapidly, suggesting that dysfunction of the rejecting heart is secondary to the interstitial edema, vascular engorgement, and cellular infiltration, causing restriction of diastolic filling. These cardiovascular signs appear to aid detection of early cardiac rejection and allow treatment at an earlier stage of the rejection process.