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JAMA Cardiology Clinical Challenge
September 20, 2017

Chest Pain and Shortness of Breath After a Heart Transplant

Author Affiliations
  • 1Brigham and Women’s Hospital, Center for Advanced Heart Failure/Cardiomyopathy, Boston, Massachusetts
JAMA Cardiol. Published online September 20, 2017. doi:10.1001/jamacardio.2017.2337

A 34-year-old man with a history of ischemic cardiomyopathy requiring a heart transplant 11 months earlier presented to the hospital with subacute onset of shortness of breath. His posttransplant course was notable for moderate cellular rejection (International Society for Heart and Lung Transplantation grade 2R) within the first 6 weeks, which was treated with a pulse of corticosteroids. Subsequently, he had normal allograft function with no further rejection noted on routine surveillance biopsies. Three days prior to this presentation, he experienced an episode of mild chest pain associated with radiation down his left arm and vomiting. He did not seek medical attention at that time as he felt the pain was unlikely to be coming from his heart. Over the preceding days, he developed progressive dyspnea on exertion, which prompted him to present to the emergency department. His electrocardiogram (ECG) on presentation is shown in Figure, A. His bedside echocardiogram showed anteroseptal akinesis with apical thrombus and reduced left ventricular function (Figure, B and Video).

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