Discussion
Isolated primary cardiac lymphoma is an exceptional post-transplant
complication with only very rare cases previously reported to the best
of our knowlegde (4). The appropriate treatment strategy remains
challenging. We decided not to propose a second heart transplantation
taking account the uncertain risk of recurrence on the graft. Indeed,
only few papers suggested such therapeutic option for primary cardiac
tumors but with heterogeneous results (5,6).
Considering the immunosuppressive strategy, we chose an
immunosuppressive quadritherapy (Prednisolone, mycophénolate mofétil,
éverolimus, ciclosporine), before the lymphoma, in order to use lower
dose of calcineurin inhibitors. However this strategy may be associated
with an increase in infectious and neoplastic complications and place
and benefits of such quadritherapy remain matter of debate.
To prevent sudden death in this case, we implanted an endocavitary ICD.
The arrhythmia triggering factor was obvious but its persistence and the
eventuality of a post-treatment fibrosis area was uncertain. Moreover,
we considered that the rhythmic risk would remain high even at a
distance from the lymphoma. Radiofrequency catheter ablation might be an
interesting option for such patients but the procedure seems associated
with high risks including tumor spreading or ventricular
hyperexcitability. Additionally, the penetration of the radiofrequency
current would be probably insufficient due to the large tumoral masses.
More recently few teams developed non-invasive ablation methods of the
VT using external radiation (7). This procedure might have been
interesting in this case as it presents the double benefit of enhanced
security of the procedure and of transmural ablation that might have
been beneficial to the lymphoma treatment.
Conclusion :
Primary cardiac lymphoma of the graft is a very rare complication with a
very poor prognosis. Its management and treatment remain discussed in
this population. Adaptation of immunosuppression and development of
non-invasive radiofrequency ablation techniques might be interesting
research track in the future.