Navigating Heart Transplantation in a Highly Sensitized Patient with Takayasu Arteritis: The Role of Perioperative Desensitization

Introduction: Takayasu arteritis (TA) is a rare large-vessel vasculitis that in selected patients can lead to severe cardiovascular complications, including advanced heart failure (HF), requiring heart transplantation (HTx). Marked pre-transplant high levels of anti-HLA antibodies and notable sensitization substantially complicate donor selection and may prolong time spent on transplant waitlists. In highly sensitized recipients, HTx may therefore require individualized perioperative desensitization strategies to reduce the risk of antibody-mediated graft injury. Case Summary: We present the case of a 46-year-old woman with TA and advanced HF who underwent HTx after individualized perioperative desensitization in the setting of significant pre-transplant sensitization (PRA > 60%). Her postoperative course required intensive clinical and immunological monitoring and treatment. The early PT course was complicated by severe clinical deterioration, including a life-threatening episode of asystole that occurred in temporal association with peak anti-HLA class I and II antibody levels. Discussion: The case highlights the complexity of alloimmune management in a patient with TA and marked pre-transplant sensitization. Also, the temporal relationship between peak antibody levels and clinical instability suggests the need for close immune surveillance, tailored desensitization and individualized immunosuppressive treatment strategies in this high-risk group. Conclusions: This case describes the clinical course of a highly sensitized patient with TA who underwent HTx following an individualized perioperative desensitization strategy based on a modified Hannover protocol. Although transplantation was followed by substantial postoperative complications, the patient remained clinically stable during follow-up. The efficacy of the modified desensitization strategy cannot be established from a single case.