Catheterization and Cardiovascular Diagnosis 1953-55 (1 990) Atrialization of Right Ventricular Pressure During Acute Cardiac Allograft Rejection Eduardo de Marchena, MD, William Madrid, MD, Paula Wozniak, BS, Laurie Futterman, RN, BSN, CCRN, Alberto Mitrani, MD, and Hooshang Bolooki, MD We describe a patient who, during an episode of acute cardiac rejection, developed such severe systolic dysfunction that there was transient near-adynamicfunction of the right ventricle. This right ventricular dysfunction was reflected hemodynamically by the un- usual finding of atrializationof right ventricular pressures.The patient’s cardiac function returned to normal after treatment with extensive immunotherapy. Key words: systolic dysfunction; graft rejection, cardiac INTRODUCTION zyxwvutsrq Although the incidence of acute allograft rejection re- sulting in graft failure has decreased with the use of cyclosporine, it is still seen at times [l]. When this he- modynamic catastrophy occurs, it can result in rapid, overwhelming systolic dysfunction. We describe a case of severe cardiac rejection resulting in biventricular fail- ure. The right ventricular systolic dysfunction was so severe that the intracavitary pressure tracings of the right heart became indistinguishable. This is the first time that this unusual hemodynamic pattern has been found during cardiac rejection. CASE REPORT zyxwvutsrq A 40-year-old white man underwent an uncomplicated orthotopic cardiac transplantation. One week after sur- gery, the cardiac allograft had a normal left ventricular ejection fraction by echocardiogram. The patient was on standard triple-drug therapy, including cyclosporine, azathioprine, and prednisone. Immunosuppression was slowly tapered, guided by endomyocardial biopsy. Four weeks after the transplant, the patient developed leg swelling and abdominal distension over a period of 24 hr and was admitted for evaluation. Since discharge from the hospital, the patient had no limitation in activity and had tolerated 30 min of cardiac rehabilitation just a few hours prior to admission. Four days before, an endomyo- cardial biopsy had demonstrated only mild rejection by Billingham criteria, with mild perivascular lymphocyte infiltration and no interstitial infiltrates [2]. The physical examination on admission revealed the patient to be in no acute distress, with a blood pressure of 110/90 mm Hg, and a pulse of 90 beats per minute. zyxwvu 0 1990 Wiley-Liss, Inc. There was mild jugular venous distension. The lungs were clear to auscultation. The cardiac examination was remarkable for a loud, presystolic gallop. There was marked tender hepatomegaly (14 cm liver span) and mild pedal edema. With the presumptive diagnosis of acute rejection, the patient was given 1 gm of intravenous (IV) methylpred- nisolone and was prepared for an endomyocardial biopsy 8 hr later. Over the subsequent 8 hr, the patient devel- oped mild shortness of breath and the arterial blood pres- sure dropped to 90160 mm Hg. A right heart catheterization was performed, demon- strating right ventricular dysfunction with atrialization of right ventricular pressures (right atrial pressure A-wave 28 mm Hg, V-wave 28 mm Hg; right ventricular pres- sure A wave 30 mm Hg, V-wave 30 mm Hg; pulmonary artery pressure 30/22 mm Hg) (Fig. 1B,C). A hand con- trast injection into the right ventricle demonstrated nearly imperceptible right ventricular contraction and tricuspid regurgitation. A dopamine infusion was begun to support the patient hemodynamically. Pressure measurements of right heart system by catheter pull back from the pulmo- nary artery to the right ventricle reconfirmed the atrial- zy From the Division of Cardiology, Surgical Nursing, Cardiovascular Surgery, Department of Pathology, and Cardiac Transplant Program of the University of Miami, and the Veterans Administration Medical Center, Miami. Received March 27, 1989; revision accepted July 22, 1989. Address reprint requests to Eduardo de Marchena, MD, Assistant Professor of Medicine, Department of Cardiology (D-39), University of Miami School of Medicine, P.O. Box 016960, Miami, FL 33101.