TOTAL LYMPHOID IRRADIATION AS RESCUE THERAPY AFTER HEART-TRANSPLANTATION

Background: Allograft dysfunction develops in a proportion of heart tr ansplant recipients without significant cellular infiltrate in endomyo cardial biopsies and with normal coronary arteries at angiography. The mechanisms responsible for this presentation are unclear, and the pro gnosis is poor. We report encouraging experience with total lymphoid i rradiation given in addition to cyclosporine A, cyclophosphamide, and prednisolone therapy in three heart transplant recipients with poor gr aft function with normal endomyocardial biopsies and coronary angiogra phy. Methods: Three patients who had severe allograft dysfunction afte r orthotopic heart transplantation, with normal endomyocardial biopsie s and coronary angiography, were successfully treated with total lymph oid irradiation. Biventricular failure developed in each patient despi te immunosuppression with cyclosporine A, azathiaprine, oral prednisol one, cyclophosphamide, and intravenous methylprednisolone therapy. Tot al lymphoid irradiation was given with standard mantle and inverted y fields over 10 treatments to achieve a cumulative dose of 8 Gy. Result s: Each patient had a significant improvement in clinical response and in ventricular performance after total lymphoid irradiation, which wa s well tolerated in each case. The patients remain well at 8, 9, and 1 2 months after completion of treatment. Conclusions: Total lymphoid ir radiation should be considered as adjunct therapy to conventional immu nosuppression for heart transplant recipients with poor graft function in the absence of cellular rejection or coronary artery disease.