Abstract 4139613: Orthotopic Heart Transplant in a Patient with Chronic Lymphocytic Leukemia: Challenges in Management

Description of Case: A 67-year-old female with a long-standing history of chronic lymphocytic leukemia (CLL, stage 0) on surveillance protocol, end stage heritable cardiomyopathy (titin mutation positive) with ejection fraction 15% and severe mitral regurgitation was referred to our center for advanced therapy evaluation. On evaluation, right heart catheterization showed normal filling pressures but decreased cardiac index (RA 4, PCWP 8, CI 1.6), so she was started on milrinone and listed for transplant as UNOS status 4 exception after extensive discussion regarding advanced therapies in the setting of her low-grade malignancy with favorable outcome. She underwent orthoptic heart transplantation (OHT) with DCD donor and ex-vivo perfusion. The preoperative total leukocytes count was 71,700/μl with mild anemia but no thrombocytopenia. Retrospective crossmatch was notable for flow cytometry crossmatch positive but CDC negative. The post-operative course was significant for an increase in total leukocyte count to 110,000/μl in absence of fever or infective source but was complicated with SVC stenosis at anastomotic site and thrombosis of the SVC and innominate vein necessitating thrombectomy and stent placement in the SVC. She also had bilateral pleural effusions for which she had bilateral chest tubes for three weeks post-transplant. Standard immunosuppression without induction was given and graft function was preserved with biopsies negative for rejection. Discussion: This case describes a successful OHT in a patient with long-standing chronic lymphocytic leukemia with a favorable outcome. OHT is the most effective therapy for end-stage heart disease, however historically cancer patients were considered ineligible for this therapy, given the increased risk with post-transplant immunosuppression. Though literature is limited, it is suggested that a careful selection of patients may have favorable outcome with slightly increased risk of cancer. These patients are at increased risk of infections and complications related to immunosuppression, which may exacerbate the immunocompromised state and potential rapid progression of underlying malignancy. Hematologic malignancies increase thromboembolism risk, as seen with this patient. A multi-disciplinary team approach involving oncology and infectious disease is integral for optimizing care in this complex population.