Case Report
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Jun 6, 2021; 9(16): 3966-3970
Published online Jun 6, 2021. doi: 10.12998/wjcc.v9.i16.3966
Chest pain in a heart transplant recipient: A case report
Yu-Jen Chen, Chien-Sung Tsai, Tsai-Wang Huang
Yu-Jen Chen, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
Chien-Sung Tsai, Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
Tsai-Wang Huang, Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
Author contributions: Chen YJ and Huang TW performed the surgery, reviewed the literature, and contributed to the drafting of the manuscript; Tsai CS was responsible for the revision of the manuscript for important intellectual content; all authors issued final approval for the version to be submitted.
Informed consent statement: Informed written consent was obtained from the patient to publish this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Tsai-Wang Huang, PhD, Associate Professor, Chief Doctor, Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, No. 325 Sec.2, Chenggong Road, Neihu District, Taipei 11490, Taiwan. chi-wang@yahoo.com.tw
Received: November 26, 2020
Peer-review started: November 26, 2020
First decision: January 23, 2021
Revised: January 26, 2021
Accepted: April 12, 2021
Article in press: April 12, 2021
Published online: June 6, 2021
Abstract
BACKGROUND

Heart transplantation is recommended for the treatment of patients with refractory heart failure. Chest pain after heart transplantation is usually considered noncardiac owing to the denervated heart. However, data from case reports on tacrolimus-induced achalasia after heart transplantation are limited. We aimed to present a case of tacrolimus-induced achalasia that developed after heart transplantation, which was successfully relieved by laparoscopic Heller myotomy.

CASE SUMMARY

A 67-year-old man with a history of Type 2 diabetes mellitus, hyperlipidemia, and dilated cardiomyopathy had congestive heart failure following orthotopic heart transplantation with tacrolimus treatment 12 years ago. At the 10-year follow-up after the heart transplantation, the patient presented with persistent cough, dysphagia, heartburn, and retrosternal chest pain lasting for 2 wk. Upper endoscopy revealed no specific findings. Two years later, the patient experienced the same symptoms, including chest pain lasting for 4 wk. Esophagogram and manometry confirmed the presence of achalasia. Previous reports showed that discontinuing calcineurin inhibitor (CNI) treatment and endoscopic botulinum toxin injection could treat CNI-induced achalasia. Owing to the risk of rejection of the transplanted heart and considering the temporary benefits of botulinum toxin injection in achalasia, the patient underwent laparoscopic Heller myotomy. Dysphagia was relieved without complications. Eight months later, he had no signs of recurrence of the achalasia.

CONCLUSION

In transplant patients with chest pain and gastrointestinal symptoms, CNI-induced achalasia may be one of the differential diagnoses. Esophagogram/manometry is useful for diagnosis.

Keywords: Heart transplantation, Refractory heart failure, Chest pain, Achalasia, Esophagogram, Case report

Core Tip: Chest pain after heart transplantation usually present with noncardiac symptoms due to the denervated heart. Its differential diagnosis includes acute allograft dysfunction caused by acute myocardial infarction, myocarditis, hypertensive crisis, or infections. However, data from case reports on tacrolimus-induced achalasia after heart transplantation are limited. In this case involving a rare complication of tacrolimus-induced achalasia after heart transplantation, we successfully treated the patient with laparoscopic Heller myotomy. This case highlights that calcineurin inhibitor -induced achalasia should be considered in transplant patients with atypical chest pain. Esophagogram or manometry may be helpful for its diagnosis.