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Cardiac Transplant Rejection — EECC MCQ

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HardHeart FailureCardiac Transplant RejectionEECC

A 62-year-old man is admitted with acute decompensated heart failure 6 weeks after cardiac transplantation. Endomyocardial biopsy shows interstitial and perivascular infiltration with mononuclear cells and associated myocyte damage. The biopsy grade is reported as ISHLT 2R. What is the most appropriate treatment?

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Correct answer: C — Pulse intravenous methylprednisolone followed by augmented oral immunosuppression

ISHLT grade 2R (moderate) acute cellular rejection is characterised by multifocal aggressive mononuclear cell infiltration with myocyte damage and requires treatment. Standard management is pulse intravenous methylprednisolone (typically 500 mg-1 g daily for 3 days) followed by augmented maintenance immunosuppression and repeat endomyocardial biopsy in 1-2 weeks to confirm resolution. Grade 1R (mild) rejection without haemodynamic compromise is typically monitored. Grade 3R (severe) rejection with haemodynamic compromise may require anti-thymocyte globulin in addition to steroids. Plasmapheresis is used for antibody-mediated rejection.

Reference: ISHLT Guidelines on Heart Transplant Management