cardio.acute-hf.transplant-recipient.v1

ADHF in cardiac transplant recipient (CAV / ACR / AMR)

cardiologyacuteadultacuteinpatienttransitionoutpatient

Start encounter →Print handoutPRODUCTION

Phase E adjacent-disease variant of cardio.acute-hf.core.v1 — narrowed to ADHF in cardiac transplant recipients. Differential dominated by allograft-specific entities: cardiac allograft vasculopathy (CAV), acute cellular rejection (ACR per ISHLT 2010), antibody-mediated rejection (AMR per ISHLT 2013). Workup pivots: STAT echo + troponin + BNP + DSA panel + endomyocardial biopsy (gold standard). Treatment specialization: pulse methylprednisolone for 2R+ ACR; IVIG + plasmapheresis + rituximab for AMR; revascularization or re-transplant for severe CAV. Critical avoid: NSAIDs (allograft nephrotoxicity); over-reduction of CNI (rejection precipitant). All transplant-recipient ADHF must trigger transplant program co-management. Manifest pointer reuses cardio.acute-hf.core.v1 manifest. Design-brief pointer reuses parent. Status INTEGRATED; authored 2026-05-14 by shard-06-cardio-acute (Phase E wave 7).

Entry points (4)

symptom
Heart transplant recipient with new dyspnea / orthopnea / edema (concern for rejection or CAV)
transplant_recipient_with_dyspnea_or_edema
lab_abnormality
Unexplained troponin or BNP rise in transplant recipient (rejection screen)
graft_troponin_or_bnp_rise
imaging
New LVEF reduction on surveillance echo in transplant recipient
new_lvef_drop_in_transplant
history
Positive donor-specific antibody (DSA) titer + clinical decompensation → AMR concern
dsa_positivity_with_clinical_change

Required inputs (12)

agerequired
demographic • used at CONTEXT
Recipient age + transplant vintage shape CAV vs rejection probability
transplant_daterequired
history • used at CONTEXT
Time post-transplant: <1 yr → ACR/AMR dominate; >5 yr → CAV dominates (ISHLT 2023)
current_immunosuppressionrequired
history • used at CONTEXT
Tacrolimus/cyclosporine (CNI) trough levels + MMF + prednisone regimen drives differential and adjustment plan
sbprequired
vital • used at RED_FLAGS
Hypotension + graft dysfunction → cardiogenic shock pathway; CNI-related vasoplegia possible
troponinrequired
lab • used at INITIAL_WORKUP
Graft injury marker; persistent rise without ischemia → rejection until proven otherwise
nt_probnprequired
lab • used at INITIAL_WORKUP
Diagnostic + monitoring; rises with both rejection and CAV-driven dysfunction
creatininerequired
lab • used at CONTEXT
CNI nephrotoxicity baseline; informs imaging contrast safety + diuretic dosing
cni_troughrequired
lab • used at CONTEXT
Sub-therapeutic CNI trough → rejection risk; supratherapeutic → toxicity (KDIGO transplant 2009)
dsa_panelrequired
lab • used at BRANCHING_WORKUP
Donor-specific antibodies — required for AMR diagnosis (ISHLT 2013 AMR criteria)
echo_statrequired
imaging • used at INITIAL_WORKUP
STAT echo for new LV/RV dysfunction; restrictive pattern can suggest rejection
endomyocardial_biopsyrequired
imaging • used at BRANCHING_WORKUP
Gold standard for ACR grading (ISHLT 2010 1R/2R/3R) and AMR (pAMR0–pAMR3)
coronary_angio_or_ivus
imaging • used at BRANCHING_WORKUP
CAV diagnosis + staging (ISHLT CAV 1/2/3 per stenosis severity + LV dysfunction)

12-phase flow (11)

1FRAME
Heart transplant recipient with acute decompensation — differential is allograft-specific (CAV vs ACR vs AMR vs non-allograft causes); inherits ADHF arc from cardio.acute-hf.core.v1
inputs: transplant_date, current_immunosuppression
advance: transplant context confirmed
2ENTRY
Transplant recipient + new dyspnea/edema/troponin rise/echo change (any one trigger)
inputs: age
advance: one entry trigger present
3CONTEXT
Transplant vintage, full immunosuppression regimen with troughs, baseline LVEF, CAV history, DSA history (KDIGO transplant 2009)
inputs: transplant_date, current_immunosuppression, cni_trough, creatinine
advance: transplant context complete
4RED_FLAGS
Cardiogenic shock (graft failure SCAI C+); hemodynamically significant AMR; severe CAV with multivessel stenosis; opportunistic infection mimic
inputs: sbp, troponin
actions: cardiogenic_shock
advance: red flags screened or escalated
5INITIAL_WORKUP
STAT echo + troponin + NT-proBNP + BMP + CBC + CMV/EBV PCR + lactate; CXR; pulse CNI trough
inputs: troponin, nt_probnp, echo_stat
actions: panel.cardiac, panel.renal
advance: baseline transplant labs + STAT echo documented
6BRANCHING_WORKUP
DSA panel + endomyocardial biopsy (ISHLT grading); coronary angiography + IVUS for CAV per ISHLT staging; rule out infection/PTLD
inputs: dsa_panel, endomyocardial_biopsy
actions: acute_pulm_edema
advance: rejection grading + CAV status documented
7DIFFERENTIAL
Assign rejection class — ACR 1R/2R/3R per ISHLT 2010 (PMID 21177015); AMR pAMR0/pAMR1/pAMR2/pAMR3; CAV ISHLT 1/2/3; non-allograft (sepsis, PE, CNI cardiotoxicity)
inputs: endomyocardial_biopsy, dsa_panel
advance: allograft diagnosis class assigned
8RISK_STRATIFICATION
AMR + LV dysfunction = highest mortality; CAV ISHLT 3 = re-transplant trigger; ACR 3R = pulse steroids ± ATG
inputs: endomyocardial_biopsy
advance: risk class documented
9TREATMENT
ACR 2R+ → pulse methylprednisolone 1 g IV × 3 d; AMR → IVIG + plasmapheresis + rituximab; CAV → PCI vs CABG (rare in graft) vs re-transplant; ADHF supportive care; AVOID NSAIDs (graft nephrotoxicity); CNI dose-adjust narrowly
inputs: cni_trough, creatinine
actions: protocol.cardiogenic_shock
advance: targeted rejection/CAV therapy started
10DISPOSITION
CICU if AMR or shock; transplant ward otherwise; transplant program co-management mandatory
advance: unit + transplant team co-management activated
11MONITORING
Repeat troponin q12h × 48 h; CNI troughs daily; surveillance biopsy at 2 wk, 4 wk, 12 wk after rejection treatment; DSA q month × 3 (ISHLT 2023)
inputs: troponin, cni_trough
actions: panel.renal
advance: post-treatment monitoring plan in place