Heart Transplant Rejection

What is heart transplant rejection?

A heart transplant is a treatment for end-stage heart failure. It’s an option if you have symptoms of heart failure despite optimal treatment with medications and medical devices. During a heart transplant, a surgeon removes your heart and replaces it with a heart from a donor who has died.

Your body may see the donor heart as a foreign object and attack it. This is called heart transplant rejection. Rejection is most common in the first several weeks after transplantation, but it can happen months or years later.

Rejection can lead to complications, such as:

• Arrhythmia: An abnormal heart rhythm that can cause sudden death.
• Failure of the new heart.
• Heart attack.

Before a heart transplant, you’ll take immunosuppressant medications. These try to control your immune system so it doesn’t attack the new organ. But immunosuppressants don’t always prevent rejection.

Are there different types of heart transplant rejection?

There are three main types of heart transplant rejection:

• Acute cellular rejection: This happens when T cells from your immune system attack the new heart’s cells. It’s most common within three to six months after transplantation.
• Chronic rejection: Chronic rejection happens over a long period of repeat attacks from your immune system. It often involves the thickening of your coronary arteries, which supply your heart muscle with oxygen and nutrients.
• Humoral rejection: Also called acute antibody rejection, this can develop at any time after transplantation. Antibodies from your immune system damage the blood vessels, preventing proper blood flow to your heart.

How common is heart transplant rejection?

Heart transplant rejection is common among people who’ve received transplantation, even in those who take all their immunosuppressant medications. But it’s becoming less common over time as scientists learn more about immunosuppression.

Does anything put me more at risk for heart transplant rejection?

Certain factors can increase the risk of rejection, including:

• Certain medical conditions in the heart recipient, such as high cholesterol, insulin resistance and pulmonary hypertension.
• Genetic mismatch between the heart donor and heart recipient.
• Heart disease in the heart donor.
• Injury to the donor heart during any step in the process.
• Heart recipient is Black.
• Heart recipient is much younger than the heart donor.
• Missed doses of immunosuppressive medications or if they stop working as well due to interactions with a new medication.

What causes heart transplant rejection?

Heart transplant rejection happens when your immune system recognizes a donor heart as a foreign object. It sends T cells or antibodies to attack the invader.

This can occur even with antirejection drugs for heart transplant patients. Scientists don’t fully understand why it happens.

What are the symptoms of heart transplant rejection?

Heart transplant rejection can occur with no symptoms at all. That’s why it’s important to attend all of your follow-up tests so your healthcare provider can screen for problems. But some recipients do experience symptoms.

Signs of heart transplant rejection may include flu-like symptoms, such as:

• Belly (abdominal) pain.
• Body aches.
• Chills.
• Fatigue.
• Low fever.
• Nausea or loss of appetite.
• Not feeling well.

Other possible heart transplant rejection symptoms include:

• Dizziness or fainting.
• Heart palpitations (noticeable heartbeat that is fast or irregular).
• Less pee (urine) than usual (oliguria).
• Low blood pressure (hypotension).
• Shortness of breath (dyspnea).
• Sudden, unexpected weight gain.
• Swollen ankles, hands or feet.

How is heart transplant rejection diagnosed?

After heart transplantation, you’ll have regular checkups to monitor for rejection. Your healthcare providers may order certain tests, such as:

• Blood tests that check for DNA markers associated with rejection.
• Echocardiogram (echo).
• Electrocardiogram (ECG or EKG).
• Nuclear cardiac stress test.
• Angiography.
• Intravascular ultrasound.
• Myocardial (heart) biopsy.

What happens after heart transplant rejection?

Treatment for heart transplant rejection depends on many factors, including:

• Type of rejection.
• Severity of rejection.
• Symptoms.
• Other health problems.
• Current medications.

If you experience heart transplant rejection, your healthcare providers may:

• Change the types of immunosuppressant drugs you’re taking, add new ones or increase dosages.
• Conduct plasmapheresis or photopheresis, processes that filter your blood.
• Perform surgery or other procedures to improve blood flow, such as angioplasty or open-heart surgery.
• Prescribe corticosteroids such as prednisone.
• Repeat transplantation with a new donor heart.
• Use mechanical support for your heart, such as extracorporeal membrane oxygenator (ECMO) or a ventricular assist device.

How can I prevent heart transplant rejection?

Certain strategies may help you prevent heart transplant rejection:

• Attend all follow-up appointments.
• Check your weight, blood pressure and temperature regularly.
• Make healthy choices, such as eating right, getting regular exercise and quitting smoking.
• Report any symptoms to your healthcare provider right away. Don’t wait until your next appointment.
• Take all medications exactly as prescribed.
• Check with your doctor or pharmacist before taking any new medications to be sure they don’t have interactions with your antirejection medications.

What can I expect if I experience heart transplant rejection?

The chances of heart transplant rejection decrease over time, but it can occur years after surgery.

If you experience heart transplant rejection, your healthcare provider will talk to you about your options. Many people can manage the condition with increased immunosuppressants and other treatments. About 2% to 4% of people who’ve had a heart transplant receive a repeat transplant.

What can I ask my doctor about heart transplant rejection?

Consider asking your healthcare provider the following questions about heart transplant rejection.

Before surgery:

• Is this donor a good match for me?
• How can I reduce my risk of heart transplant rejection?
• What antirejection medications should I take?
• What are the side effects of antirejection medications?
• How often should I check my weight, blood pressure and temperature? And what changes should I call you about?

If you experience rejection:

• What type of rejection am I experiencing?
• What treatments might help?
• Am I eligible for another transplant?

A note from Cleveland Clinic

Organ rejection is common after heart transplant surgery. It can occur days to years after transplantation. Talk to your healthcare provider about ways to decrease rejection risk and possible treatment options.