Acute Rejection of the Allografted Human Heart: Diagnosis and Treatment

Twenty-six patients have received heart transplants at Stanford University Medical Center. Of these, 11 were alive at six months (42%), 10 at twelve and eighteen months (37%), and 7 at twenty-four months (26%). Sixty episodes of acute allograft rejection were diagnosed in 21 patients. No correlation between histocompatibility match and rejection history was apparent. Emphasis was placed on early diagnosis of rejection episodes and intermittent use of high-dose immunosuppressive therapy. Useful indexes of early graft rejection included electrocardiographic changes (decreasing QRS voltage, appearance of arrhythmias, right shift of the electrical axis, ST-T wave changes), clinical findings (appearance of gallop rhythm, decreased precordial activity, hypotension), and ultrasound echocardiographic findings (increased thickness of left ventricular wall, increased right ventricular diameter). Fifty-seven rejection episodes were reversed with increased immunosuppressive therapy, and 3 progressed to graft failure and the patient's death. In the cardiac transplant recipient, monitoring multiple indexes of allograft function allows the early diagnosis and successful treatment of most episodes of acute rejection.