Intermediate term results of total lymphoid irradiation for the treatment of non-specific graft dysfunction after heart transplantation

Background: A proportion of heart transplant recipients develop poor graft function in the absence of cellular infiltrate in endomyocardial biopsies o r transplant associated coronary artery disease. The condition has a poor p rognosis and its aetiology is poorly understood. We report encouraging inte rmediate term results with total lymphoid irradiation (TLI) in the manageme nt of this condition. Methods: Eleven adult cardiac transplant recipients w ho developed seven allograft dysfunction (NYHA class-4) at a median period of 4 months after orthotopic heart transplantation were successfully treate d with TLI. Endomyocardial biopsies and coronary angiography were normal in each patient and biventricular failure developed in spite of immunosuppres sion with Cyclosporin-A, Azathioprine, oral Prednisolone, Cyclophosphamide and intravenous Methylprednisolone therapy. Total lymphoid irradiation was given with standard Mantle and inverted Y-fields over ten treatments to ach ieve a cumulative dose of 8 Gy. Results: Each patient had a significant imp rovement in clinical response and in ventricular performance within 2 month s of commencing TLI. Nine patients are currently well (four NHYA class-1, f ive NHYA class-2) at 4-38 (median 26) months following TLI. Two patients di ed; one from bacterial septicaemia and one as a consequence of chronic rena l failure. Three patients developed opportunistic infection which was succe ssfully treated with appropriate antimicrobial agents. An Ebstein-Barr viru s associated lymphoproliferative disorder occurred in one patient and was s uccessfully treated by reduction in immunosuppression and high dose Acyclov ir. Two patients developed transient bone marrow suppression. Conclusion: T he intermediate term results of TLI in the management of poor graft functio n in cardiac transplant recipients with normal endomyocardial biopsies and coronary angiography are encouraging. Although complications of opportunist ic infection, bone marrow suppression and lymphoproliferative disorder occu rred, treatment was successful in each case. (C) 1999 Elsevier Science B.V. All rights reserved.