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Table 1.  

Therapy Class

Therapy Name(s)

Induction immunosuppression

High-dose corticosteroids

Prednisone, methylprednisolone

Cytolytic therapy

Anti-thymocyte Ig

Interleukin-2 receptor inhibitor

Basiliximab

Maintenance immunosuppression 

Corticosteroids

Prednisone, methylprednisolone

Calcineurin inhibitors

Tacrolimus, cyclosporine

Cell-cycle inhibitors

MMF, azathioprine

Proliferation signal inhibitors

Sirolimus, everolimus

ACR treatment*

High-dose corticosteroids

Prednisone, methylprednisolone

Cytolytic therapy†

Anti-thymocyte Ig

AMR treatment*

High-dose corticosteroids

Prednisone, methylprednisolone

Cytolytic therapy

Anti-thymocyte Ig

CD20 inhibitor

Rituximab, obinutuzumab

Proteosome inhibitor

Bortezomib

Complement inhibitor

Eculizumab

Ig

Intravenous IgG

Plasmapheresis

 

Table 1. General Immunosuppressive Therapies Used After HT and for Rejection Treatment[1,8,9]

*Optimize maintenance immunosuppression and can add rejection treatment.
The failing graft may also be supported with inotropic agents and mechanical circulatory support.

Table 2.  

ACR Grade

2005 Scale

1990 Scale

No ACR

0 R

0

Mild

1 R

1A, 1B, 2

Moderate

2 R

3A

Severe

3 R

3B, 4

Table 2. Comparison of 2005 and 1990 ACR Grading Scales[1,5,12]

Table 3.  

Grade

Definition

Substrates

pAMR 0

Negative for pathologic AMR

Histologic and immunopathologic studies are both negative.

pAMR 1 (H+)

Histopathologic AMR alone

Histologic findings are present and immunopathologic findings are negative.

pAMR 1 (I+)

Immunopathologic AMR alone

Histologic findings are negative and immunopathologic findings are positive (CD68+ and/or C4d+).

pAMR 2

Pathologic AMR

Histologic and immunopathologic findings are both present.

pAMR 3

Severe pathologic AMR

Interstitial hemorrhage, capillary fragmentation, mixed inflammatory infiltrates, endothelial cell pyknosis, and/or karyorrhexis, and marked edema and immunopathologic findings are present. These cases may be associated with profound hemodynamic dysfunction and poor clinical outcomes.

Table 3. The 2013 ISHLT Working Formulation for Pathologic Diagnosis of AMR in HT[6]

Table 4.  

Major Complications

Minor Complications

Death (0%-0.07%)

Chest pain (transient)(0%-1.8%)

Cardiac perforation, hemopericardium, tamponade (0%-6.9%)

Deep vein thrombosis(0.23%-3.8%)

Pneumothorax, air embolism (0%-0.8%)

Puncture site hematoma, nerve palsy (0%-0.64%)

Thromboembolism (0%-0.32%)

Hypotension, vasovagal syncope (0%-4.3%)

Valvular trauma (0.02%-1.10%)

Arterial trauma, vascular damage, fistulae (0.32%-2.80%)

Severe arrhythmias, atrioventricular block (0%-11%)

 

Table 4. Major and Minor Complications of EMB[22]

CME / ABIM MOC

Rethinking the Paradigm in Cardiac Transplant Rejection Surveillance

  • Authors: Josef Stehlik, MD, MPH
  • CME / ABIM MOC Released: 3/23/2022
  • Valid for credit through: 3/23/2023
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  • Credits Available

    Physicians - maximum of 1.00 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 1.00 ABIM MOC points

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for cardiologists, transplant surgeons and other HCPs who work with patients who have received a heart transplant.

After participating in the activity, learners will understand current standards in cardiac allograft transplant monitoring and how novel, noninvasive modalities may impact the current standard of care.

Upon completion of this activity, participants will:

  • Have increased knowledge regarding the
    • Clinical manifestations of acute cardiac transplant rejection
    • Current standard of care in transplant rejection monitoring and diagnosis
    • Clinical applicability of available noninvasive monitoring technologies


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Faculty

  • Josef Stehlik, MD, MPH

    Professor of Medicine
    University of Utah School of Medicine
    Salt Lake City, Utah

    Disclosures

    Consultant or advisor for: Medtronic, Inc; Natera; Sanofi; TransMedics, Inc.
    Research funding from: Natera

Editors

  • Joy P. Marko, MS, APN-C, CCMEP

    Senior Medical Education Director, Medscape, LLC

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    Associate Medical Writer, Medscape, LLC

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  • Leigh Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

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CME / ABIM MOC

Rethinking the Paradigm in Cardiac Transplant Rejection Surveillance

Authors: Josef Stehlik, MD, MPHFaculty and Disclosures

CME / ABIM MOC Released: 3/23/2022

Valid for credit through: 3/23/2023

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Educational Impact Challenge

After participating in the activity, learners will understand current standards in cardiac allograft transplant monitoring and how novel, noninvasive modalities may impact the current standard of care.

Before you begin this activity, please assess your clinical knowledge by completing this brief survey. Answering these questions again after the activity will allow you to see what you learned and to compare your answers with those of your peers.