Acute Orthotopic Heart Transplantation Rejection With ST-Segment Elevation in Leads I and aVL

Acute allograft rejection is a prominent cause of graft failure in heart transplant recipients. Graft infiltration with immune-mediated cells is associated with changes in electric conduction. ECG patterns in heart transplant rejection generally include changes in the electric activity of the atria. ST-segment elevation is an uncommon presentation in acute rejection. We describe a case of mixed cellular and humoral rejection in a 74-year-old man 5 years after orthotopic heart transplantation presenting with lateral ST-segment elevations on ECG and normal coronary arteries on coronary angiography. Endomyocardial biopsy revealed International Society for Heart and Lung Transplantation grade 3R severe acute cellular rejection with associated pAMR1 (I+) antibody–mediated rejection.A 74-year-old man with chronic heart failure caused by an ischemic cardiomyopathy who underwent heart transplantation 5 years previously presented with left-sided chest pain of 4 days duration. Associated symptoms included dyspnea on exertion, fatigue, orthopnea, paroxysmal nocturnal dyspnea, and nausea. The past medical history was notable for an episode of acute cellular rejection 4 years before admission. The patient’s medications included aspirin, rosuvastatin, clonidine, and a 2-drug immunosuppresion regimen consisting of …