Chronic rejection in human heart transplantation.

The more prevalent complication in patients with a long survival rate after heart transplantation is chronic rejection, which was studied in a series of 80 necropsies and five cardiac grafts surgically removed for retransplantation after chronic rejection. In the material obtained at necropsy, 11 of 14 patients with a survival rate of more than 6 months died from chronic rejection. Clinically, the usual manifestation was heart failure. Anatomic angiograms were performed in several cases. They demonstrated narrowing and nonopacification of small coronary arteries, often accompanied by thrombosis and ischemic complications. The histologic study detected three types of rejection. (1) The more typical rejection is observed after 6 months. It is characterized by a stenosing fibrous endarteritis. (2) Another type of rejection occurs earlier and is associated with acute rejection; its anatomic substratum is an inflammatory panarteritis. (3) This type of rejection is accompanied by large atheromatous deposits. The significance and pathogenesis of these lesions are discussed in correlation with their clinical context and with the electron microscopic observations.