Heart transplantation pathophysiology

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Heart transplantation Microchapters


Patient Information


Historical Perspective




Epidemiology and Demographics

Risk Factors


Complications and Prognosis





Criteria for Cardiac Transplantation

Equitable Distribution of Donor Hearts to those Awaiting Transplantation and the Process of Being Listed for a Transplant


Medical Therapy



Electrocardiogram and Pacing After Cardiac Transplantation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ifrah Fatima, M.B.B.S[2]


The pathogenesis leading to a cardiac transplant involves the mechanisms leading up to heart failure. Heart failure leads to an inadequate output of the heart to meet the metabolic demands of the body. Features of chronic heart failure like biventricular hypertrophy, four-chamber dilatation, fibrotic scars, myofibrillar loss, sarcoplasmic vacuolation, interstitial fibrosis may be seen in the diseased heart. Post-transplantation changes indicating acute or chronic rejection may be seen. Non-rejection changes include coronary artery disease (eccentric), Quilty effect, interstitial fibrosis, nodular lymphocytic endomyocardial infiltrates, and posttransplant lymphoproliferative disorder in the transplanted heart.



Cardiac Transplantation is the treatment for patients with intractable heart failure, not amenable to medical and device therapy.

It is understood that heart failure is the end result of many causes- Common causes whose pathogenesis results in the need for cardiac transplantation may include:[1]

  • Systolic Heart Failure with a low Left Ventricular Ejection Fraction( <35%) may be caused by
  • Ischemic Coronary Artery Disease with Refractory Angina
  • Long-standing Intractable life-threatening Arrhythmias
    • Ventricular arrhythmias
  • Cardiomyopathies
    • Restrictive and Hypertrophic Cardiomyopathies
    • Non-dilated cardiomyopathies
  • Congenital Heart Disease
    • Many congenital heart defects that are not amenable to surgery lead to New York Heart Association functional class IV Heart Failure

Gross Pathology

Pre-transplantation or Recipient Heart

On gross pathology, features of chronic heart failure are seen-

Post-transplantation or Donor Heart

On gross pathology, features of acute or chronic rejection may be seen, if the patient is not on adequate immunosuppressive therapy. [3]

Microscopic Pathology

Pre-transplantation or Recipient Heart

Post-transplantation or Donor Heart

Changes associated with Rejection

Features of mild acute rejection include [4]-

Features of moderate acute rejection include-

Features of severe acute rejection additionally include-

Features of chronic rejection include-

Types of rejection

Type (grade) Description Details of microscopic pathology
antibody-mediated rejection (acute vascular) edema, dilated small vessels scant inflammation
normal (0R) normal no extravascular monocytes
acute cellular (1R) (perivascular) inflammatory infiltrate, myocyte damage scant interstitial infiltrate (lymphoplasmacytic), scant damage
acute cellular (2R) (perivascular) inflammatory space-occupying lesion diffuse interstitial infiltrate displaces parenchyma (lymphoplasmacytic), obvious damage (myocyte eosinophilia or drop-out)
acute cellular (3R) disruption of normal arch. diffuse interstitial infiltrate disrupts parenchyma (lymphoplasmic & PMNs), fibre loss/damage
chronic concentric intimal thicking internal elastic lamina preserved (unlike atherosclerosis)

Nonrejection changes

  • Coronary Artery Disease- Arteriosclerosis- concentric intimal thickening associated with endovasculitis. This is to be compared with ordinary atherosclerosis where lipids are deposited mainly in the endothelium and subendothelium in an eccentric pattern.
  • Other changes like- [3]
    • Ischemic changes
    • Interstitial fibrosis
    • Mycoytes- hypertrophy, calcification
    • Nodular lymphocytic endomyocardial infiltrates- Seen with the use of Cyclosporin, known as Quilty effect [6]
    • Posttransplant lymphoproliferative disorder- Similar to large cell lymphoma


  1. Mehra MR, Canter CE, Hannan MM, Semigran MJ, Uber PA, Baran DA; et al. (2016). "The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update". J Heart Lung Transplant. 35 (1): 1–23. doi:10.1016/j.healun.2015.10.023. PMID 26776864.
  2. 2.0 2.1 Pomerance A, Stovin PG (1985). "Heart transplant pathology: the British experience". J Clin Pathol. 38 (2): 146–59. doi:10.1136/jcp.38.2.146. PMC 499095. PMID 2981905.
  3. 3.0 3.1 3.2 3.3 Tazelaar HD, Edwards WD (1992). "Pathology of cardiac transplantation: recipient hearts (chronic heart failure) and donor hearts (acute and chronic rejection)". Mayo Clin Proc. 67 (7): 685–96. doi:10.1016/s0025-6196(12)60726-5. PMID 1434905.
  4. Tan CD, Baldwin WM, Rodriguez ER (2007). "Update on cardiac transplantation pathology". Arch Pathol Lab Med. 131 (8): 1169–91. doi:10.1043/1543-2165(2007)131[1169:UOCTP]2.0.CO;2. PMID 17683180.
  5. 5.0 5.1 Boilson BA, McGregor CG, Kushwaha SS (2011). "Pathophysiological changes after cardiac transplantation: the role of chronic inflammation and rejection". Heart. 97 (20): 1634–5. doi:10.1136/heartjnl-2011-300526. PMID 21727202.
  6. Pardo-Mindán FJ, Lozano MD (1991). ""Quilty effect" in heart transplantation: is it related to acute rejection?". J Heart Lung Transplant. 10 (6): 937–41. PMID 1756159.

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