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Issitt RW, Cudworth E, Cortina-Borja M, Gupta A, Kallon D, Crook R, Shaw M, Robertson A, Tsang VT, Henwood S, Muthurangu V, Sebire NJ, Burch M, Fenton M. Rapid desensitization through immunoadsorption during cardiopulmonary bypass. A novel method to facilitate human leukocyte antigen incompatible heart transplantation. Perfusion 2024; 39:543-554. [PMID: 36625378 PMCID: PMC10943618 DOI: 10.1177/02676591221151035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Anti-human leukocyte antigen (HLA)-antibody production represents a major barrier to heart transplantation, limiting recipient compatibility with potential donors and increasing the risk of complications with poor waiting-list outcomes. Currently there is no consensus to when desensitization should take place, and through what mechanism, meaning that sensitized patients must wait for a compatible donor for many months, if not years. We aimed to determine if intraoperative immunoadsorption could provide a potential desensitization methodology. METHODS Anti-HLA antibody-containing whole blood was added to a Cardiopulmonary bypass (CPB) circuit set up to mimic a 20 kg patient undergoing heart transplantation. Plasma was separated and diverted to a standalone, secondary immunoadsorption system, with antibody-depleted plasma returned to the CPB circuit. Samples for anti-HLA antibody definition were taken at baseline, when combined with the CPB prime (on bypass), and then every 20 min for the duration of treatment (total 180 min). RESULTS A reduction in individual allele median fluorescence intensity (MFI) to below clinically relevant levels (<1000 MFI), and in the majority of cases below the lower positive detection limit (<500 MFI), even in alleles with a baseline MFI >4000 was demonstrated. Reduction occurred in all cases within 120 min, demonstrating efficacy in a time period usual for heart transplantation. Flowcytometric crossmatching of suitable pseudo-donor lymphocytes demonstrated a change from T cell and B cell positive channel shifts to negative, demonstrating a reduction in binding capacity. CONCLUSIONS Intraoperative immunoadsorption in an ex vivo setting demonstrates clinically relevant reductions in anti-HLA antibodies within the normal timeframe for heart transplantation. This method represents a potential desensitization technique that could enable sensitized children to accept a donor organ earlier, even in the presence of donor-specific anti-HLA antibodies.
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Affiliation(s)
- Richard W Issitt
- Perfusion Department, Great Ormond Street Hospital for Children, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
- Digital Research, Informatics and Virtual Environment, NIHR Great Ormond Street Biomedical Research Centre, London, UK
| | - Eamonn Cudworth
- Clinical Transplantation Laboratory, Barts Health NHS Trust, London, UK
| | - Mario Cortina-Borja
- Population, Policy and Practice Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Arun Gupta
- Clinical Transplantation Laboratory, Barts Health NHS Trust, London, UK
| | - Delordson Kallon
- Clinical Transplantation Laboratory, Barts Health NHS Trust, London, UK
| | - Richard Crook
- Perfusion Department, Great Ormond Street Hospital for Children, London, UK
| | - Michael Shaw
- Perfusion Department, Great Ormond Street Hospital for Children, London, UK
| | - Alex Robertson
- Perfusion Department, Great Ormond Street Hospital for Children, London, UK
| | - Victor T Tsang
- Institute of Cardiovascular Science, University College London, London, UK
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, London, UK
| | - Sophie Henwood
- Department of Cardiothoracic Transplantation, Great Ormond Street Hospital for Children, London, UK
| | - Vivek Muthurangu
- Institute of Cardiovascular Science, University College London, London, UK
| | - Neil J Sebire
- Digital Research, Informatics and Virtual Environment, NIHR Great Ormond Street Biomedical Research Centre, London, UK
| | - Michael Burch
- Institute of Cardiovascular Science, University College London, London, UK
- Department of Cardiothoracic Transplantation, Great Ormond Street Hospital for Children, London, UK
- Department of Paediatric Cardiology, Institute of Child Health, University College London, London, UK
| | - Matthew Fenton
- Department of Cardiothoracic Transplantation, Great Ormond Street Hospital for Children, London, UK
- Department of Paediatric Cardiology, Institute of Child Health, University College London, London, UK
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2
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Davies E, Khan S, Mo YD, Jacquot C, Dham N, Sinha P, Webb J. Modifications to therapeutic plasma exchange to achieve rapid exchange on cardiopulmonary bypass prior to pediatric cardiac transplant. J Clin Apher 2023; 38:514-521. [PMID: 37042579 PMCID: PMC10567986 DOI: 10.1002/jca.22053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 02/08/2023] [Accepted: 03/29/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Cardiac transplants increasingly occur following placement of ventricular assist devices (VADs). A strong association exists between human leukocyte antigen (HLA) sensitization and VAD placement; however, desensitization protocols that utilize therapeutic plasma exchange (TPE) are fraught with technical challenges and are at increased risk of adverse events. In response to increased VAD utilization in our pre-transplant population, we developed a new institutional standard for TPE in the operating room. METHODS Through a multidisciplinary effort, we developed an institutional protocol for intraoperative TPE immediately prior to cardiac transplantation after cannulation onto cardiopulmonary bypass (CPB). All procedures used the standard TPE protocol on the Terumo Optia (Terumo BCT, Lakewood, CO, USA), but incorporated multiple modifications to limit patients' bypass times, and to coordinate with the surgical teams. These modifications included deliberate misidentification of replacement fluid and maximization of the citrate infusion rate. RESULTS These adjustments allowed the machine to run at maximal inlet speeds, minimizing duration of TPE. To date, 11 patients have been treated with this protocol. All survived their cardiac transplantation operation. Hypocalcemia and hypotension were noted; however, none of these adverse events appeared to have clinical impact. Technical complications included unexpected fibrin deposition in the TPE circuit and air in the inlet line due to surgical manipulation of the CPB cannula. No thromboembolic complications occurred in any patient. CONCLUSION We feel that this procedure can be rapidly and safely performed in HLA sensitized pediatric patients on CPB to limit the risk of antibody mediated rejection of their heart transplant.
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Affiliation(s)
- Emily Davies
- Division of Pediatric Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Sairah Khan
- Division of Cardiology and Cardiac Transplant, Children's National Hospital, Children's National Heart Institute, Washington, District of Columbia, USA
| | - Yunchuan D Mo
- Division of Laboratory and Transfusion Medicine, Children's National Hospital, Washington, District of Columbia, USA
- Center for Cancer and Blood Disorders, Division of Hematology, Children's National Hospital, Washington, District of Columbia, USA
| | - Cyril Jacquot
- Division of Laboratory and Transfusion Medicine, Children's National Hospital, Washington, District of Columbia, USA
- Center for Cancer and Blood Disorders, Division of Hematology, Children's National Hospital, Washington, District of Columbia, USA
| | - Niti Dham
- Division of Cardiology and Cardiac Transplant, Children's National Hospital, Children's National Heart Institute, Washington, District of Columbia, USA
| | - Pranava Sinha
- Division of Pediatric Cardiac Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jennifer Webb
- Division of Laboratory and Transfusion Medicine, Children's National Hospital, Washington, District of Columbia, USA
- Center for Cancer and Blood Disorders, Division of Hematology, Children's National Hospital, Washington, District of Columbia, USA
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3
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Hullin R, Meyer P, Yerly P, Kirsch M. Cardiac Surgery in Advanced Heart Failure. J Clin Med 2022; 11:jcm11030773. [PMID: 35160225 PMCID: PMC8836496 DOI: 10.3390/jcm11030773] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/27/2022] [Accepted: 01/27/2022] [Indexed: 02/05/2023] Open
Abstract
Mechanical circulatory support and heart transplantation are established surgical options for treatment of advanced heart failure. Since the prevalence of advanced heart failure is progressively increasing, there is a clear need to treat more patients with mechanical circulatory support and to increase the number of heart transplantations. This narrative review summarizes recent progress in surgical treatment options of advanced heart failure and proposes an algorithm for treatment of the advanced heart failure patient at >65 years of age.
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Affiliation(s)
- Roger Hullin
- Cardiology, Cardiovascular Department, University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland;
- Correspondence: ; Tel.: +41-21-314-0052
| | - Philippe Meyer
- Cardiology, Department of Medical Specialties, Geneva University Hospital, University of Geneva, Rue du Gabrielle Perret-Gentil 4, 1205 Geneva, Switzerland;
| | - Patrick Yerly
- Cardiology, Cardiovascular Department, University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland;
| | - Matthias Kirsch
- Cardiac Surgery, Cardiovascular Department, University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland;
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4
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Lee HJ, Shin KH, Kim HH, Je HG, Kim D, Cho WH, Kim JS, Lee SY, Yeo HJ. Successful Desensitization by Post-Centrifugal Plasma Filtration in Two Highly Sensitized Heart and Lung Transplant Recipients. Ann Lab Med 2021; 40:431-434. [PMID: 32311860 PMCID: PMC7169625 DOI: 10.3343/alm.2020.40.5.431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/06/2020] [Accepted: 03/03/2020] [Indexed: 11/19/2022] Open
Affiliation(s)
- Hyun-Ji Lee
- Department of Laboratory Medicine and Research, Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Kyung-Hwa Shin
- Department of Laboratory Medicine, Pusan National University Hospital, Busan, Korea
| | - Hyung-Hoi Kim
- Department of Laboratory Medicine, Pusan National University Hospital, Busan, Korea
| | - Hyung Gon Je
- Department of Cardiovascular and Thoracic Surgery and Research, Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dohyung Kim
- Department of Cardiovascular and Thoracic Surgery and Research, Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Woo Hyun Cho
- Department of Pulmonology and Critical Care Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jeong Su Kim
- Division of Cardiology, Department of Internal Medicine and Research, Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Soo Yong Lee
- Division of Cardiology, Department of Internal Medicine and Research, Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Hye Ju Yeo
- Department of Pulmonology and Critical Care Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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5
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Morgan AE, Dewey E, Mudd JO, Gelow JM, Davis J, Song HK, Tibayan FA, Bhamidipati CM. The role of estrogen, immune function and aging in heart transplant outcomes. Am J Surg 2019; 218:737-743. [DOI: 10.1016/j.amjsurg.2019.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/05/2019] [Accepted: 07/16/2019] [Indexed: 11/24/2022]
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7
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Ma C, Tolpin D, Anton J. Con: Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation Should Not Always Have a Left Ventricular Vent Placed. J Cardiothorac Vasc Anesth 2019; 33:1163-1165. [DOI: 10.1053/j.jvca.2018.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Indexed: 11/11/2022]
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8
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Bhagra SK, Pettit S, Parameshwar J. Cardiac transplantation: indications, eligibility and current outcomes. Heart 2018; 105:252-260. [DOI: 10.1136/heartjnl-2018-313103] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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9
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Kobashigawa J, Colvin M, Potena L, Dragun D, Crespo-Leiro MG, Delgado JF, Olymbios M, Parameshwar J, Patel J, Reed E, Reinsmoen N, Rodriguez ER, Ross H, Starling RC, Tyan D, Urschel S, Zuckermann A. The management of antibodies in heart transplantation: An ISHLT consensus document. J Heart Lung Transplant 2018; 37:537-547. [PMID: 29452978 DOI: 10.1016/j.healun.2018.01.1291] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Accepted: 01/18/2018] [Indexed: 12/19/2022] Open
Abstract
Despite the successes from refined peri-operative management techniques and immunosuppressive therapies, antibodies remain a serious cause of morbidity and mortality for patients both before and after heart transplantation. Patients awaiting transplant who possess antibodies against human leukocyte antigen are disadvantaged by having to wait longer to receive an organ from a suitably matched donor. The number of pre-sensitized patients has been increasing, a trend that is likely due to the increased use of mechanical circulatory support devices. Even patients who are not pre-sensitized can go on to produce donor-specific antibodies after transplant, which are associated with worse outcomes. The difficulty in managing antibodies is uncertainty over which antibodies are of clinical relevance, which patients to treat, and which treatments are most effective and safe. There is a distinct lack of data from prospective trials. An international consensus conference was organized and attended by 103 participants from 75 centers to debate contentious issues, determine the best practices, and formulate ideas for future research on antibodies. Prominent experts presented state-of-the-art talks on antibodies, which were followed by group discussions, and then, finally, a reconvened session to establish consensus where possible. Herein we address the discussion, consensus points, and research ideas.
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Affiliation(s)
- Jon Kobashigawa
- Advanced Heart Disease Section, Cedars-Sinai Heart Institute, Los Angeles, California, USA.
| | - Monica Colvin
- Cardiovascular Division, University of Michigan, Ann Arbor, Michigan, USA
| | - Luciano Potena
- Department of Specialist, Diagnostic, and Experimental Medicine, Bologna University Hospital, Bologna, Italy
| | - Duska Dragun
- Center for Cardiovascular Research, Charité Universtätsmedizin, Berlin, Germany
| | - Maria G Crespo-Leiro
- Heart Failure and Heart Transplant Program, Hospital Universitario A Coruña, Coruña, Spain
| | - Juan F Delgado
- Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Michael Olymbios
- Advanced Heart Disease Section, Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | | | - Jignesh Patel
- Advanced Heart Disease Section, Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Elaine Reed
- UCLA Immunogenetics Center, Los Angeles, California, USA
| | - Nancy Reinsmoen
- Department of Immunology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - E Rene Rodriguez
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Heather Ross
- Ted Rogers Centre of Excellence in Heart Function, University of Toronto, Toronto, Ontario, Canada
| | - Randall C Starling
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Dolly Tyan
- Department of Clinical Pathology, Stanford University Medical Center, Palo Alto, California, USA
| | - Simon Urschel
- Division of Pediatric Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Andreas Zuckermann
- Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria
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10
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Sumler M, Vadlamudi R. Preanesthetic evaluation of the patient with end-stage heart failure. Best Pract Res Clin Anaesthesiol 2017; 31:179-188. [PMID: 29110791 DOI: 10.1016/j.bpa.2017.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 05/10/2017] [Accepted: 06/16/2017] [Indexed: 11/15/2022]
Abstract
Heart failure (HF) currently affects more than 5 million patients in the United States [1]. Advanced HF is associated with high mortality and poor quality of life. It is estimated that between 5% and 10% of all patients with HF have an advanced form of the disease [1]. Orthotopic heart transplantation (OHT) is an accepted therapy for stage D HF [3] (Fig. 1). Unfortunately, the number of patients with the disease exceeds the number of available organs. This makes appropriate patient selection vital in the field of heart transplantation. Anesthetic evaluation of the patient presenting for OHT or mechanical circulatory support (MCS) implantation is a vital component of the patient's perioperative course. Patients often have had extensive diagnostic testing and assessment prior to being listed for OHT or considered for MCS implantation. Because of the often urgent nature of these procedures, the cardiac anesthesiologist must conduct a focused review of the relevant information and perform a focused patient interview and physical exam.
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Affiliation(s)
- Michele Sumler
- Emory University, Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, United States.
| | - Ratna Vadlamudi
- Emory University, Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, United States.
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11
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Weng PL, Alejos JC, Halnon N, Zhang Q, Reed EF, Tsai-Chambers E. Long-term outcomes of simultaneous heart and kidney transplantation in pediatric recipients. Pediatr Transplant 2017; 21:10.1111/petr.13023. [PMID: 28727227 PMCID: PMC5638697 DOI: 10.1111/petr.13023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2017] [Indexed: 11/30/2022]
Abstract
Pediatric sHKTx has become an effective therapy for patients with combined cardiac and renal failure. Often, these patients develop human leukocyte antigen antibodies from their previous allografts and are therefore more difficult to re-transplant. We describe the largest case series of a predominantly sensitized pediatric sHKTx with emphasis on medical management and patient outcomes. Demographics, clinical characteristics, antibody, and biopsy data were retrospectively collected from University of California, Los Angeles database and correlated with short- and long-term patient and allograft outcomes of all sHKTx performed between 2002 and 2015. We identified seven pediatric patients who underwent sHKTx at our center. Mean age at time of sHKTx was 13.7 years and 85.7% were re-graft patients. 57.1% were sensitized with cPRA >50% and another 57.1% had preformed donor-specific antibody. Five-year renal allograft survival and patient survival was 85.7% for both end-points. The remaining six patients are all alive (mean follow-up 78.5 months) with good kidney and heart function. sHKTx in a population with increased immunological risk can be associated with good long-term outcomes and offers potential guidance to the pediatric transplant community where data are limited.
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Affiliation(s)
- Patricia L. Weng
- Division of Pediatric Nephrology, Mattel Children's Hospital UCLA, Los Angeles, CA, USA
| | - Juan Carlos Alejos
- Division of Pediatric Cardiology, Mattel Children's Hospital UCLA, Los Angeles, CA, USA
| | - Nancy Halnon
- Division of Pediatric Cardiology, Mattel Children's Hospital UCLA, Los Angeles, CA, USA
| | - Qiuheng Zhang
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, University of California, Los Angeles, CA, USA
| | - Elaine F. Reed
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, University of California, Los Angeles, CA, USA
| | - Eileen Tsai-Chambers
- Division of Pediatric Nephrology, Duke University Medical Center, Durham, NC, USA
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12
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The Approach to Antibodies After Heart Transplantation. CURRENT TRANSPLANTATION REPORTS 2017; 4:243-251. [DOI: 10.1007/s40472-017-0162-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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13
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Ozturk P, Ertugay S, Sahutoglu C, Engin C, Nalbantgil S, Yagdi T, Ozbaran M. Short-term Results of Heartmate 3 Ventricular Assist Device Implantation for End-Stage Heart Failure. Transplant Proc 2017; 49:599-602. [PMID: 28340840 DOI: 10.1016/j.transproceed.2017.01.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To report our initial experience with Heartmate 3 ventricular assist device (HM3) in cases with end-stage heart failure (ESHF). METHODS Charts of 8 ESHF patients who underwent HM3 implantation in our clinic from January to June 2016 (group 1) and 16 patients who underwent HM2 implantation during 2015 (group 2) were reviewed retrospectively. Demographics as well as pre- and early postoperative medical data were noted and statistically analyzed between the 2 groups. RESULTS No statistical difference was found in age or sex distribution between groups (P > .05). Mean Interagency Registry for Mechanically Assisted Circulatory Support scores were 2.13 ± 0.99 and 3.38 ± 0.72 in groups 1 and 2, respectively (P = .020). Mean cardiopulmonary bypass time, and chest tube drainage fluid volume and blood product requirement during intensive care unit (ICU) stay were 64.0 ± 13.9 minutes, 1,112.5 ± 516.7 mL, and 318.8 ± 271.2 mL, respectively, in group 1 and 89.0 ± 33.3 minutes, 2,081.3 ± 1,696.0 mL, and 1,118.8 ± 1,010.8 mL in group 2 (P = .027, P = .019, and P = .040, respectively). Need for surgical revision and early mortality were not evident for group 1, although 4 cases (25.0%) required revision surgery, and early mortality was seen in 3 cases (18.8%) in group 2 (P = .121 and P = .190, respectively). Mean durations of ICU stay and total postoperative hospitalization were 5.9 ± 2.0 and 18.3 ± 5.5 days, respectively in group 1 and 6.2 ± 4.3 and 18.0 ± 6.9 days in the surviving 13 patients of the group 2 (P = .645 and P = .697, respectively). CONCLUSIONS With its shorter implantation time and reduced blood product requirement in the early postoperative period, the HM3 system was found to be safe and effective in ESHF treatment.
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Affiliation(s)
- P Ozturk
- Department of Cardiovascular Surgery, Ege University School of Medicine, Izmir, Turkey.
| | - S Ertugay
- Department of Cardiovascular Surgery, Ege University School of Medicine, Izmir, Turkey
| | - C Sahutoglu
- Department of Anesthesiology, Ege University School of Medicine, Izmir, Turkey
| | - C Engin
- Department of Cardiovascular Surgery, Ege University School of Medicine, Izmir, Turkey
| | - S Nalbantgil
- Department of Cardiology, Ege University School of Medicine, Izmir, Turkey
| | - T Yagdi
- Department of Cardiovascular Surgery, Ege University School of Medicine, Izmir, Turkey
| | - M Ozbaran
- Department of Cardiovascular Surgery, Ege University School of Medicine, Izmir, Turkey
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O'Connor MJ, Keeshan BC, Lin KY, Monos D, Lind C, Paridon SM, Mascio CE, Shaddy RE, Rossano JW. Changes in the methodology of pre-heart transplant human leukocyte antibody assessment: an analysis of the United Network for Organ Sharing database. Clin Transplant 2015; 29:842-50. [PMID: 26172275 DOI: 10.1111/ctr.12590] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND We sought to investigate temporal trends in the methodology of human leukocyte antibody assessment in heart transplantation. METHODS The United Network for Organ Sharing database was queried from June 2004 to March 2013 to obtain pre-heart transplantation human leukocyte antibody results. The % panel reactive antibody for class I and II antibodies was recorded along with the methodology of assessment. Allosensitization was defined as class I and/or II panel reactive antibody of ≥ 10%. The primary outcome measure was graft survival. RESULTS During the study period, 12,858 patients with available data underwent heart transplantation. The prevalence of allosensitization increased, with 16.8% in 2005-2006 sensitized at the time of transplantation compared to 23.1% in 2010-2011 (p < 0.001); this occurred in conjunction with an increase in the utilization of flow cytometry (77.2% in 2005-2006; 97.0% in 2010-2011, p < 0.001). Using multivariable analysis, a positive pre-heart transplantation panel reactive antibody by flow cytometry independently predicted graft loss. CONCLUSIONS There has been a recent increase in flow cytometric assessment of human leukocyte antibodies prior to heart transplantation, which may be associated with an increase in the prevalence of pre-transplant patients being characterized as allosensitized. Flow cytometry may identify patients with the highest likelihood of graft loss.
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Affiliation(s)
- Matthew J O'Connor
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Britton C Keeshan
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kimberly Y Lin
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dimitrios Monos
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Curt Lind
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stephen M Paridon
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher E Mascio
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert E Shaddy
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph W Rossano
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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15
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Kornberg A. Intravenous immunoglobulins in liver transplant patients: Perspectives of clinical immune modulation. World J Hepatol 2015; 7:1494-1508. [PMID: 26085909 PMCID: PMC4462688 DOI: 10.4254/wjh.v7.i11.1494] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 04/19/2015] [Accepted: 05/08/2015] [Indexed: 02/06/2023] Open
Abstract
Shortage of appropriate donor grafts is the foremost current problem in organ transplantation. As a logical consequence, waiting times have extended and pretransplant mortality rates were significantly increasing. The implementation of a priority-based liver allocation system using the model of end-stage liver disease (MELD) score helped to reduce waiting list mortality in liver transplantation (LT). However, due to an escalating organ scarcity, pre-LT MELD scores have significantly increased and liver recipients became more complex in recent years. This has finally led to posttransplant decreasing survival rates, attributed mainly to elevated rates of infectious and immunologic complications. To meet this challenging development, an increasing number of extended criteria donor grafts are currently accepted, which may, however, aggravate the patients’ infectious and immunologic risk profiles. The administration of intravenous immunoglobulins (IVIg) is an established treatment in patients with immune deficiencies and other antibody-mediated diseases. In addition, IVIg was shown to be useful in treatment of several disorders caused by deterioration of the cellular immune system. It proved to be effective in preventing hyperacute rejection in highly sensitized kidney and heart transplants. In the liver transplant setting, the administration of specific Ig against hepatitis B virus is current standard in post-LT antiviral prophylaxis. The mechanisms of action of IVIg are complex and not fully understood. However, there is increasing experimental and clinical evidence that IVIg has an immuno-balancing impact by a combination of immuno-supporting and immuno-suppressive properties. It may be suggested that, especially in the context of a worsening organ shortage with all resulting clinical implications, liver transplant patients should benefit from immuno-regulatory capabilities of IVIg. In this review, perspectives of immune modulation by IVIg and impact on outcome in liver transplant patients are described.
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Picascia A, Grimaldi V, Casamassimi A, De Pascale MR, Schiano C, Napoli C. Human leukocyte antigens and alloimmunization in heart transplantation: an open debate. J Cardiovasc Transl Res 2014; 7:664-75. [PMID: 25190542 DOI: 10.1007/s12265-014-9587-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 08/20/2014] [Indexed: 10/24/2022]
Abstract
Considerable advances in heart transplantation outcome have been achieved through the improvement of donor-recipient selection, better organ preservation, lower rates of perioperative mortality and the use of innovative immunosuppressive protocols. Nevertheless, long-term survival is still influenced by late complications. We support the introduction of HLA matching as an additional criterion in the heart allocation. Indeed, allosensitization is an important factor affecting heart transplantation and the presence of anti-HLA antibodies causes an increased risk of antibody-mediated rejection and graft failure. On the other hand, the rate of heart-immunized patients awaiting transplantation is steadily increasing due to the limited availability of organs and an increased use of ventricular assist devices. Significant benefits may result from virtual crossmatch approach that prevents transplantation in the presence of unacceptable donor antigens. A combination of both virtual crossmatch and a tailored desensitization therapy could be a good compromise for a favorable outcome in highly sensitized patients. Here, we discuss the unresolved issue on the clinical immunology of heart transplantation.
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Affiliation(s)
- Antonietta Picascia
- U.O.C. Division of Immunohematology, Transfusion Medicine and Transplant Immunology [SIMT], Regional Reference Laboratory of Transplant Immunology [LIT], Azienda Ospedaliera Universitaria (AOU), Second University of Naples, Piazza L. Miraglia 2, 80138, Naples, Italy,
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Kilic A, Emani S, Sai-Sudhakar CB, Higgins RSD, Whitson BA. Donor selection in heart transplantation. J Thorac Dis 2014; 6:1097-104. [PMID: 25132976 DOI: 10.3978/j.issn.2072-1439.2014.03.23] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 03/17/2014] [Indexed: 01/17/2023]
Abstract
There is increased scrutiny on the quality in health care with particular emphasis on institutional heart transplant survival outcomes. An important aspect of successful transplantation is appropriate donor selection. We review the current guidelines as well as areas of controversy in the selection of appropriate hearts as donor organs to ensure optimal outcomes. This decision is paramount to the success of a transplant program as well as recipient survival and graft function post-transplant.
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Affiliation(s)
- Ahmet Kilic
- 1 The Department of Surgery, 2 The Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Sitaramesh Emani
- 1 The Department of Surgery, 2 The Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Chittoor B Sai-Sudhakar
- 1 The Department of Surgery, 2 The Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Robert S D Higgins
- 1 The Department of Surgery, 2 The Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Bryan A Whitson
- 1 The Department of Surgery, 2 The Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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