Rejection of a transplanted heart

Rejection is when your body’s immune system starts to ‘attack’ your transplanted heart. It happens when your immune system recognises the heart as coming from a different person and thinks it isn’t supposed to be there.

After a heart transplant, patients need to take powerful medicines (‘immunosuppressants’) to help stop rejection happening. Even if you take your anti-rejection medicines carefully, rejection can still occur. This is why your transplant team will closely monitor your health and heart function after your transplant.

Episodes of rejection occur in between 30 to 40 in 100 patients during the first year after a transplant 

Some patients have a higher risk of rejection than others. If you have had a blood transfusion, or multiple pregnancies you may have produced defence proteins (‘antibodies’). These antibodies increase the risk of rejection.

You may develop symptoms that suggest rejection. These include breathlessness, tiredness, fluid retention and weight gain, and sometimes a raised temperature.

You will undergo tests to check if your immune system is attacking the heart at intervals after the transplant.

This is done by taking a small sample of heart tissue (a biopsy) through the vein in your neck or groin. The procedure is done with local anaesthesia and takes about 30 minutes.

A result is usually available within 24 hours. The frequency of biopsies gradually decreases with time after the transplant. You are likely to undergo 10-14 biopsies in the first year even if you are well (surveillance biopsies). 

Risks of a heart biopsy

Fewer than 1 in 100 patients have serious complications after a heart biopsy.

Serious complications can occur after a heart biopsy but in fewer than 1 in 100 patients. This includes a puncture of the wall of the heart allowing blood to escape into the cavity around the heart. This can affect heart function and may require drainage of the blood either with a tube or by surgery (opening the chest). Minor complications such as bruising around the vein which is cannulated for the biopsy are more frequent (1-5 in 100 biopsies).  

Treatment is with stronger immunosuppressant medicines.

If there is evidence of rejection you will receive treatment with increased immunosuppression. If you are unwell, and rejection is suspected, you may have additional biopsies.

If acute rejection is picked up early, it can usually be treated successfully. It is possible for rejection to cause heart function to decrease markedly, but this is unusual. If heart function is affected, it may take several weeks to improve.

There are different types of rejection, depending on which parts of the immune system are attacking the organ. Different types of rejection need different treatments.

Cellular rejection

The most common type of rejection is called ‘cellular’ rejection. This can usually be treated by giving steroids into your vein. Sometimes more powerful treatment is required and this will usually require a stay in hospital.

Antibody-mediated rejection

Less commonly, but more seriously, defence proteins (‘antibodies’) cause rejection. This type of rejection is difficult to treat and you will need to come into the hospital for treatment. Your transplant team will explain this to you in more detail.

Make sure you attend all of your appointments in clinic, and take the medicines that have been prescribed for you. If you have side effects from your anti-rejection medicines, tell your transplant team so that they can talk to you about other options. Do not stop taking your immunosuppressant (anti-rejection) medicines.