Clinically the most frequent symptom associated with rejection is fatigue. Examination may reveal a relative hypotension, increased jugular venous distension, and the presence of an S3. These findings should prompt an emergent biopsy. Similarly atrial ventricular arrhythmias may be the early warning signs of rejection and biopsy is warranted.

Treatment of rejection depends on the severity as assessed by histologic grading and allograft function. Mild rejection may require increased immunosuppression if accompanied by significant cardiac dysfunction. The diagnosis of rejection is made by endomyocardial biopsy. Traditionally it is performed via percutaneous internal jugular or femoral vein puncture with fluoroscopic guidance. An internationally accepted grading scale for reporting cardiac allograft rejection has been adopted (Table 11.6).

Recommended frequency for performing surveillance right ventricular biopsy varies, but it is typically performed weekly for the first month, then every other week for another month, then monthly until six months postoperatively and then every three months until the end of the first postoperative year. At that time additional biopsies as surveillance have not shown to be of clinical significance. Aside from these routine biopsies additional biopsies are performed after treatment of rejection.

Rejection Treatment

There are a number of protocols for the treatment of rejection. After the initial biopsy demonstrates rejection, echocardiography is performed to evaluate function. Cyclosporine and azathioprine dosages are optimized and the patient receives a steroid pulse. Resolution may be seen by follow-up echocardiography and confirmed by rebiopsy. For more severe rejection ATGAM and/or OKT3 may be used with rebiopsy in 3-5 days and the steroid pulse may be continued. For severe rejection antilymphocyte treatment is extended and hemodynamic support, both

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