Treatment of Anti-Body Mediated Rejection Complicated by Cardiogenic Shock with a Temporary Left Ventricular Assist Device as a Bridge to Recovery

Introduction Anti-body mediated rejection (AMR) after cardiac transplantation is a difficult entity to diagnose and treat. Mortality rates in AMR remain high and treatment strategies vary but consist of therapies that aim to remove circulating antibodies, decrease antibody production, suppress T and B-cell responses, and inhibit complement. We report a case of AMR associated cardiogenic shock supported on Impella 5.0. Case Report : A 51-year-old man who received a cardiac transplant in 2018 was admitted for chest pain and dyspnea. Six weeks prior, he had similar symptoms with a right heart catherization (RHC) showing normal hemodynamics. Endomyocardial biopsy did not show cellular or AMR. On admission, he was found to be in cardiogenic shock SCAI stage D with severe bi-ventricular failure. RHC confirmed elevated right and left-sided filling pressures and low cardiac output (cardiac power output 0.7). Biopsy showed grade 1R cellular rejection and infiltrative quilty lesions with focal endocardial inflammation and C3d positive capillaries. He was intubated for hypoxemic respiratory failure and an Impella 5.0 was placed for left ventricular unloading and tissue perfusion in addition to milrinone and epinephrine drips. Labs were significant for new class II DSA (DQ7, DR53 immunodominant antibodies). He was treated with intravenous solumedrol, plasmapheresis, and antithymocyte globulin-rabbit (rATG, Thymoglobulin). He received multiple sessions of bortezomib infusion with plasmapheresis while supported with Impella 5.0. He improved over the following three weeks and was extubated with explant of the Impella 5.0 on day 16. His DSA's continued to decrease and graft function improved with ejection fraction up to 50% (Figure 1). He was discharged with plans for further bortezomib and plasmapheresis sessions. Summary This case demonstrates the successful treatment of cardiogenic shock precipitated by AMR with an Impella 5.0 as a bridge to recovery.