What is heart transplant rejection?

Your immune system’s job is to seek out and destroy foreign substances in the body. It destroys bacteria and viruses to help keep you healthy. Normally, this is a good thing. But sometimes the immune system’s response can lead to problems.

During a heart transplant, a surgeon removes your poorly working heart. Then, they replace it with a healthy heart from a donor. The immune system sees the new heart as a foreign object. It can start to attack it. This is called transplant rejection.

When you have a heart transplant, you will need to take certain medicines for the rest of your life. These help to prevent rejection of the new heart by your immune system. Transplant rejection is common. It can even happen in people who take all their medicines as prescribed.

The most common type of heart transplant rejection is called acute cellular rejection. This happens when your T-cells (part of your immune system) attack the cells of your new heart. It happens most often in the first 3 to 6 months after transplant.

Humoral rejection is a less common type. It’s also known as acute antibody rejection. It can develop during the first month after transplantation. Or it can happen as late as months to years after transplant. With humoral rejection, antibodies injure the blood vessels in your body. This includes your coronary arteries. This can cause problems with blood flow to the heart.

Heart transplant rejection can also be long-term (chronic). Coronary artery vasculopathy is a form of chronic rejection. It affects the coronary arteries. These supply the heart muscle with oxygen and nutrients. In coronary artery vasculopathy, the inner lining of the blood vessel thickens. This can lead to less blood going to the heart muscle. Your healthcare provider may prescribe medicines to prevent and treat this type of rejection.

What causes heart transplant rejection?

Heart transplant rejection can happen in a normally functioning immune system. Failing to take anti-rejection medicines as prescribed can cause transplant rejection. But many people who take their medicines as prescribed still have rejection. No one knows for sure why this happens.

Who is at risk for heart transplant rejection?

Certain things increase the chances of both short-term (acute) and chronic heart transplant rejection. One of the most important factors is a genetic mismatch between the heart donor and heart recipient. Younger heart recipients are also at greater risk for both kinds of rejection.

Other things that increase the chances of acute transplant rejection include:

• Time after transplantation, as rejection risk is highest several weeks after the transplant and then starts to decrease

• Being a female heart recipient or female heart donor

• Being an African-American heart recipient

Some factors that specifically increase the chances of chronic rejection include:

• High cholesterol

• Cytomegalovirus infection

• Older heart donor

• Male donor

• Younger recipient

• History of acute heart rejection

• Coronary heart disease in the donor or the recipient

• Insulin resistance

What are the symptoms of heart transplant rejection?

Some of the symptoms of acute heart transplant rejection include:

• Feeling tired or weak

• Fever or chills

• Shortness of breath

• Fast or irregular heartbeat

• Drop in blood pressure

• Swelling of your feet, hands, or ankles

• Sudden weight gain

• Flu-like aches and pains

• Reduced amounts of urine

• Dizziness or fainting

• Nausea or loss of appetite

It's common for rejection to happen without any symptoms at all. Many cases are found before symptoms develop. This is due to intense rules for screening after transplant. This is one reason why it's so important to make all your follow-up visits.

How is heart transplant rejection diagnosed?

Diagnosis starts with a recent health history, physical exam, and blood tests. Often, a healthcare provider will diagnose acute rejection with a heart biopsy. You may have multiple routine biopsies after a heart transplant. This helps them watch for rejection. These biopsies often show signs of transplant rejection before you have any symptoms. Finding a rejection early increases the chances it can be treated.

Sometimes, healthcare providers spot acute rejection with a blood test. This test checks for certain genes tied to transplant rejection. Your healthcare provider might use other standard tests to evaluate your heart function. Some examples include:

• Electrocardiogram (ECG) to monitor the heart rhythm

• Echocardiogram to evaluate heart function

Other tests are sometimes needed for the diagnosis of chronic rejection. These tests help provide a better look at the blood vessels. These may include:

• Coronary angiography

• Intravascular ultrasound

• Cardiac stress testing

How is heart transplant rejection treated?

Treatment depends on a number of factors. These include the severity of the rejection, symptoms, current medicines, and the type of rejection. Some options for treating acute cellular transplant rejection include:

• Increasing the dose of or how often you take a current anti-rejection medicine

• Changing to a different anti-rejection medicine

• Adding other medicines that suppress the immune system, such as prednisone or a similar steroid

• For more severe cases, you may need treatment with medicines given by IV (intravenous)

Plasmapheresis is one of the treatments for rejection caused by antibodies. This is called acute humoral rejection. Plasmapheresis filters the blood and removes the harmful antibodies. Sometimes, light therapy to treat the white cells in removed blood is used (photophoresis). Then, the treated blood is returned to you.

Increasing the dose of anti-rejection medicines is another way to treat chronic rejection. If the damage is more severe, you may have a lot of blockages in the coronary arteries. For this, you may need angioplasty or open-heart surgery. These procedures help blood flow better in the coronary arteries. Rarely, chronic rejection needs another transplant. Living a heart-healthy lifestyle can decrease the risk of developing chronic rejection.

After you get treatment for rejection, you will need to be closely monitored. You might need follow-up tests to see how you respond.

Medicines used to prevent rejection do suppress the immune system. This increases the risk for infection. Your risk of heart failure also increases with rejection. Because of these possible complications, your healthcare provider may give you additional medicines.

• They may give you antibiotic and antiviral medicines. These are needed if you are using certain anti-rejection medicines. They don’t treat the rejection itself, but they may help to prevent infection.

• They may give you medicines to treat heart failure, such as beta-blockers. You may need these if the rejection is severely affecting your new heart.

What are possible complications of heart transplant rejection?

In rare cases, heart transplant rejection can cause complications such as:

• Failure of the new donor heart

• Heart rhythm problems, which can sometimes cause sudden death

• Heart attack

What can I do to prevent heart transplant rejection?

You can reduce your chances of having heart transplant rejection and complications from rejection. Here are some things you can do:

• Take all of your medicines exactly as prescribed.

• Always have an adequate supply of your medicines on hand.

• Check your weight, blood pressure, and temperature as advised by your healthcare provider.

• Keep all scheduled healthcare provider appointments.

• Have your lab work and other tests done on time.

• Contact your transplant team right away if you have any signs of transplant rejection.

• Follow up on any tests with your transplant team.

• Live a heart-healthy lifestyle, including regular exercise and a healthy diet.

• Don't use tobacco products and limit alcohol.

• Stay current on vaccines for the flu and pneumonia, along with tetanus boosters as needed.

Living with a heart transplant

Your healthcare provider may have more instructions about how to manage your condition. These might include the following:

• Live a healthy lifestyle. Eat a heart-healthy diet and get enough exercise. Don't use tobacco products, illegal drugs, or too much alcohol. Stay at a healthy weight.

• Take other medicines for your heart. These might include medicines to reduce cholesterol, lower your blood pressure, or help manage your blood glucose. Some of these medicines might help lower the chances of chronic rejection as well.

When should I call my healthcare provider?

Call your transplant team right away if you have any signs of rejection. Also call if you generally don't feel well. Don't wait until your next scheduled appointment.

Key points about heart transplant rejection

• Heart transplant rejection is common after heart transplant surgery. Rejection can be acute or chronic. The immune system attacks the donated heart, leading to symptoms.

• Follow all of your healthcare provider’s instructions carefully. This will help decrease your chances of rejection. It will also make it easier for your healthcare provider to detect rejection early, when they can treat it more easily.

• Know what symptoms might be signs of heart transplant rejection. Tell your transplant team about any symptoms right away.

• You will need close monitoring to check for signs of rejection.

• The risks of acute rejection lessen with time, but rejection is always a risk. You will always need anti-rejection medicines to help prevent transplant rejection.

• Anti-rejection medicines suppress your immune system. This increases your risk for infection.

• Treatment of transplant rejection often involves increasing the dose of medicines you are taking. Your healthcare provider may add new medicines.

• Following a healthy lifestyle can help keep your heart healthy.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Know the reason for your visit and what you want to happen.

• Before your visit, write down questions you want answered.

• Bring someone with you to help you ask questions and remember what your provider tells you.

• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.

• Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.

• Ask if your condition can be treated in other ways.

• Know why a test or procedure is recommended and what the results could mean.

• Know what to expect if you do not take the medicine or have the test or procedure.

• If you have a follow-up appointment, write down the date, time, and purpose for that visit.

• Know how you can contact your provider if you have questions.