Cardiac Transplantation and the Contribution of Pathology

Abstract

Heart transplantation is a successful treatment for end-stage heart failure with international 1-year and 5-year survival rates of 81 % and 69 % and a median survival after the first year of 14 years. Assessment, transplantation, follow-up, and complications of recipients are managed by a multiprofessional multidisciplinary team which must include the pathologist. His/her role includes confirming the diagnosis in the recipient’s heart either at the time of assessment on endomyocardial biopsy or after surgery by examination of the explanted heart. Biopsy diagnosis of acute cellular and antibody-mediated rejection should be done using the Working Formulations of the International Society for Heart and Lung Transplantation. Chronic rejection/cardiac allograft vasculopathy involves the coronary arteries and is diagnosed using imaging modalities. A role for standardized biopsy diagnosis of allograft microvasculopathy has yet to be agreed. Other complications such as malignancy, infections, and other side effects of drug therapy often require access to pathology and other laboratory services. Provision of a pathology service must include rapid biopsy diagnosis and access to immunohistochemistry, cytopathology, molecular genetics, and autopsy laboratory services, all working to approved national laboratory standards. Contributing to collaborative ethically approved research using pathological tissue, retained with appropriate consent, is an important part of the pathologist’s role. The pathologist must also ensure they maintain a consistently high standard of diagnostic practice through participation in regular audit and reproducibility studies, on-going education in newer aspects of transplant medicine and immunology through specialist societies and journals, and networking with transplant pathologists in other centers. Digital resources may be of help in this regard. This chapter outlines the major areas of practice in which pathologists can contribute to the multidisciplinary care of the transplant recipient.