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Cardiac Transplant Emergencies – Spoon-Feed Version

April 8, 2021

Written by Carmen Wolfe

Spoon Feed
Cardiac transplant patients commonly present to the emergency department for acute care. Graft failure, rejection, and infection are common in the first year post-transplant, and patients are at high risk for dysrhythmias, acute coronary syndrome (ACS) including “silent MI,” cardiac allograft vasculopathy, and medication adverse effects.

Why does this matter?
Cardiac transplants are becoming more common, and these patients will be showing up to your ED for acute care when problems arise. This review article covers evaluation pearls and common complications associated with cardiac transplantation.

What could possibly go wrong…

Post-transplant Anatomy and Physiology

  • The vagus nerve is often ligated during transplant, leaving a “denervated” heart that has a higher resting heart rate, often 80-110 bpm.


  • A multidisciplinary approach is prudent, involving the patient’s transplant team.

  • ECG post-transplant may have benign common alterations: two P waves if a bicaval surgical approach is used, RBBB in 70% of patients, and PACs/PVCs in 70% of patients.

  • ECG changes associated with ACS are not substantially different in post-transplant patients.

  • Troponin/BNP may be elevated up to 3 months after transplant; new elevation after this time period is concerning.

  • Echocardiography is often helpful.

Post-transplant complications

  • Dysrhythmias

    • Bradycardia? Atropine is unlikely to be helpful due to vagal denervation.

    • Atrial fibrillation/flutter? Beta blockers are preferred over diltiazem due to CYP3A4 inhibition that increases tacrolimus/cyclosporine levels.

    • AVNRT? Vagal maneuvers are ineffective; use adenosine with caution in reduced dose (1-3 mg) due to increased SA/AV nodal sensitivity; patients often need synchronized cardioversion.

    • PVCs/NSVT?  These are common and usually benign.

    • Sustained VT? This suggests rejection or vasculopathy and needs rapid assessment.

  • Infection

    • 1st month after transplant: nosocomial, surgical site, donor organ infections

    • 1st-6th month after transplant: opportunistic infection due to immunosuppression

    • > 6 months after transplant: community-acquired “typical” infection

  • COVID-19 – Mortality approaches 25% for this population.

  • Graft dysfunction – Ventricular dysfunction may be diastolic, systolic, or both.

  • Rejection

    • This is most common within the first two years post-transplant, peaking at 1 month.

    • Signs and symptoms are myriad and not specific; definitive diagnosis requires endomyocardial biopsy and treatment is with high-dose steroids.

  • Cardiac allograft vasculopathy (CAV) and ACS

    • CAV = Accelerated CAD of the allograft vessels

    • ACS may have atypical symptoms or be “silent” due to denervation in up to 40% of patients.

  • Medication effects: Heed the med list and know the med-specific side effects (great summary in Table 4 of the full text).

A primer for managing cardiac transplant patients in the emergency department setting. Am J Emerg Med. 2021 Mar;41:130-138. doi: 10.1016/j.ajem.2020.12.071. Epub 2021 Jan 1.

What are your thoughts?