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.