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Romero E, Tabak E, Fishbein G, Litovsky S, Tallaj J, Liem D, Bakir M, Khachatoorian Y, Piening B, Keating B, Deng M, Cadeiras M. Unsupervised mRNA-seq classification of heart transplant endomyocardial biopsies. Clin Transplant 2023; 37:e15011. [PMID: 37151104 PMCID: PMC10524567 DOI: 10.1111/ctr.15011] [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: 01/21/2023] [Revised: 04/10/2023] [Accepted: 04/28/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Endomyocardial biopsy (EMB) is currently considered the gold standard for diagnosing cardiac allograft rejection. However, significant limitations related to histological interpretation variability are well-recognized. We sought to develop a methodology to evaluate EMB solely based on gene expression, without relying on histology interpretation. METHODS Sixty-four EMBs were obtained from 47 post-heart transplant recipients, who were evaluated for allograft rejection. EMBs were subjected to mRNA sequencing, in which an unsupervised classification algorithm was used to identify the molecular signatures that best classified the EMBs. Cytokine and natriuretic peptide peripheral blood profiling was also performed. Subsequently, we performed gene network analysis to identify the gene modules and gene ontology to understand their biological relevance. We correlated our findings with the unsupervised and histological classifications. RESULTS Our algorithm classifies EMBs into three categories based solely on clusters of gene expression: unsupervised classes 1, 2, and 3. Unsupervised and histological classifications were closely related, with stronger gene module-phenotype correlations for the unsupervised classes. Gene ontology enrichment analysis revealed processes impacting on the regulation of cardiac and mitochondrial function, immune response, and tissue injury response. Significant levels of cytokines and natriuretic peptides were detected following the unsupervised classification. CONCLUSION We have developed an unsupervised algorithm that classifies EMBs into three distinct categories, without relying on histology interpretation. These categories were highly correlated with mitochondrial, immune, and tissue injury response. Significant cytokine and natriuretic peptide levels were detected within the unsupervised classification. If further validated, the unsupervised classification could offer a more objective EMB evaluation.
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Affiliation(s)
- Erick Romero
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA
| | - Esteban Tabak
- Courant Institute of Mathematical Sciences, New York University, New York, NY
| | - Gregory Fishbein
- David Geffen School of Medicine, UCLA Medical Center, Los Angeles, CA
| | - Silvio Litovsky
- UAB School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Jose Tallaj
- UAB School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - David Liem
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA
| | - Maral Bakir
- David Geffen School of Medicine, UCLA Medical Center, Los Angeles, CA
| | | | - Brian Piening
- Earle A. Chiles Research Institute, Providence, Portland, Oregon
| | - Brendan Keating
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, PA
| | - Mario Deng
- David Geffen School of Medicine, UCLA Medical Center, Los Angeles, CA
| | - Martin Cadeiras
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA
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Rodriguez ER, Santos-Martins C, Tan CD. Pathology of cardiac transplantation. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00023-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Abstract
The assessment of pediatric patients after orthotropic heart transplantation (OHT) relies heavily on non-invasive imaging. Because of the potential risks associated with cardiac catheterization, expanding the role of non-invasive imaging is appealing. Echocardiography is fast, widely available, and can provide an accurate assessment of chamber sizes and function. Advanced echocardiographic methods, such as myocardial deformation, have potential to assess for acute rejection or cardiac allograft vasculopathy (CAV). While not currently part of routine care, cardiac magnetic resonance imaging (CMR) and computed tomography may potentially aid in the detection of graft complications following OHT. In particular, CMR tissue characterization holds promise for diagnosing rejection, while quantitative perfusion and myocardial late gadolinium enhancement may have a role in the detection of CAV. This review will evaluate standard and novel methods for non-invasive assessment of pediatric patients after OHT.
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Affiliation(s)
- Jonathan H Soslow
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Margaret M Samyn
- Medical College of Wisconsin, Pediatrics (Cardiology), Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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4
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Lim HS, Hsich E, Shah KB. International Society of Heart and Lung Transplantation position statement on the role of right heart catheterization in the management of heart transplant recipients. J Heart Lung Transplant 2018; 38:235-238. [PMID: 30638836 DOI: 10.1016/j.healun.2018.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/18/2018] [Indexed: 01/06/2023] Open
Affiliation(s)
- Hoong Sern Lim
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom.
| | | | - Keyur B Shah
- The Pauley Heart Center, Virginia Commonwealth University Medical Center, Richmond, Virginia
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Antończyk K, Niklewski T, Antończyk R, Zakliczyński M, Zembala M, Kukulski T. Evaluation of the Graft Mechanical Function Using Speckle-Tracking Echocardiography During the First Year After Orthotropic Heart Transplantation. Ann Transplant 2018; 23:554-560. [PMID: 30087315 PMCID: PMC6248016 DOI: 10.12659/aot.909359] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Recent advances in ultrasound strain imaging facilitate more precise monitoring of subtle myocardial changes and thus may allow for more appropriate assessment of myocardium after orthotopic heart transplantation (OHT). This study aimed to explore longitudinal left ventricular (LV) and right ventricular (RV) function by speckle-tracking echocardiography (STE) during a 12-month follow-up period in relation to acute cellular rejection (ACR) degree ≥2R and the response to intense immunosuppressive therapy with intravenous steroids. Material/Methods Forty-five adult heart transplant recipients were prospectively assessed at a single center from January 2016 until June 2017. Echocardiography was performed serially at baseline and together with routine biopsies at 2 weeks and 1, 2, 3, 6, 9, and 12 months after OHT. Changes in graft function were evaluated using STE before and during ACR and in the resolving period of ACR. Results A total of 220 pairs of biopsy specimens and strain recordings were analyzed. Moderate ACR was seen in 30 biopsies (13.6%). In the serial assessment, longitudinal strain parameters of the LV (global and 4-, 2-, 3-chamber longitudinal strain) and RV (global and free wall longitudinal strain) were decreased at baseline and improved significantly (P<0.001) within 12 months after OHT. The degree of improvement was not influenced by ACR. There were no significant differences in circumferential, radial, or longitudinal strain rate, or mechanical dyssynchrony. Reduced LV and RV longitudinal strain was related to ACR degree 2R and increased significantly (P<0.0005) during 3 days of intravenous methylprednisolone therapy. Conclusions Using the STE technique, we have documented an acute improvement in mechanical myocardial function following ACR steroid therapy and a progressive recovery of LV and RV longitudinal function during the first year after OHT.
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Affiliation(s)
- Karolina Antończyk
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, SMDZ in Zabrze, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, SMDZ in Zabrze, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Tomasz Niklewski
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, SMDZ in Zabrze, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Remigiusz Antończyk
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, SMDZ in Zabrze, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Michael Zakliczyński
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, SMDZ in Zabrze, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Marian Zembala
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, SMDZ in Zabrze, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Tomasz Kukulski
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, SMDZ in Zabrze, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
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Three-Dimensional Self-Navigated T2 Mapping for the Detection of Acute Cellular Rejection After Orthotopic Heart Transplantation. Transplant Direct 2017; 3:e149. [PMID: 28405605 PMCID: PMC5381742 DOI: 10.1097/txd.0000000000000635] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 10/04/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND T2 mapping is a magnetic resonance imaging technique measuring T2 relaxation time, which increases with the myocardial tissue water content. Myocardial edema is a component of acute cellular rejection (ACR) after heart transplantation. This pilot study compares in heart transplantation recipients a novel high resolution 3-dimensional (3D) T2-mapping technique with standard 2-dimensional (2D) T2-mapping for ACR detection. METHODS Consecutive asymptomatic patients (n = 26) underwent both 3D T2 mapping and reference 2D T2 mapping magnetic resonance imaging on the day of endomyocardial biopsy (EMB). 3D T2 maps were obtained at an isotropic spatial resolution of 1.72 mm (voxel volume 5.1 mm3). 2D and 3D maps were matched anatomically, and maximum segmental T2 values were compared blinded to EMB results. In addition, all 3D T2 maps were rendered as 3D images and inspected for foci of T2 elevation. RESULTS T2 values of segments from 2D and reformatted 3D T2 maps agreed (p > 0.5). The highest 2D segmental T2 values were 49.9 ± 4.0 ms (no ACR = 0R, n = 18), 48.9 ± 0.8 ms (mild ACR = 1R, n = 3), and 65.0 ms (moderate ACR = 2R). Rendered 3D T2 maps of cases with 1R showed foci with significantly elevated T2 signal (T2 = 58.2 ± 3.6 ms); 5 cases (28%) in the 0R group showed foci with increased T2 values (>2 SD above adjacent tissue) that were not visible on the 2D T2 maps. CONCLUSIONS This pilot study in a small cohort suggests equivalency of standard segmental analysis between 3D and 2D T2-mapping. 3D T2 mapping provides a spatial resolution that permits detection of foci with elevated T2 in patients with mild ACR.
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Juvet SC, Sanderson S, Hester J, Wood KJ, Bushell A. Quantification of CD4(+) T Cell Alloreactivity and Its Control by Regulatory T Cells Using Time-Lapse Microscopy and Immune Synapse Detection. Am J Transplant 2016; 16:1394-407. [PMID: 26603026 PMCID: PMC4855688 DOI: 10.1111/ajt.13607] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 10/07/2015] [Accepted: 11/03/2015] [Indexed: 01/25/2023]
Abstract
Assays designed to select transplant recipients for immunosuppression withdrawal have met with limited success, perhaps because they measure events downstream of T cell-alloantigen interactions. Using in vitro time-lapse microscopy in a mouse transplant model, we investigated whether transplant outcome would result in changes in the proportion of CD4(+) T cells forming prolonged interactions with donor dendritic cells. By blocking CD4-MHC class II and CD28-B7 interactions, we defined immunologically relevant interactions as those ≥500 s. Using this threshold, T cell-dendritic cell (T-DC) interactions were examined in rejection, tolerance and T cell control mediated by regulatory T cells. The frequency of T-DC contacts ≥500 s increased with T cells from mice during acute rejection and decreased with T cells from mice rendered unresponsive to alloantigen. Regulatory T cells reduced prolonged T-DC contacts. Importantly, this effect was replicated with human polyclonally expanded naturally occurring regulatory T cells, which we have previously shown can control rejection of human tissues in humanized mouse models. Finally, in a proof-of-concept translational context, we were able to visualize differential allogeneic immune synapse formation in polyclonal CD4(+) T cells using high-throughput imaging flow cytometry.
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Affiliation(s)
- S. C. Juvet
- Transplantation Research Immunology GroupNuffield Department of Surgical SciencesJohn Radcliffe HospitalUniversity of OxfordOxfordUK,Toronto Lung Transplant Program and Division of RespirologyDepartment of MedicineUniversity Health Network and University of TorontoTorontoOntarioCanada,Present address: Toronto General HospitalTorontoOntarioCanada
| | - S. Sanderson
- NIHR BRC Translational Immunology LaboratoryNuffield Department of MedicineJohn Radcliffe HospitalUniversity of OxfordOxfordUK
| | - J. Hester
- Transplantation Research Immunology GroupNuffield Department of Surgical SciencesJohn Radcliffe HospitalUniversity of OxfordOxfordUK
| | - K. J. Wood
- Transplantation Research Immunology GroupNuffield Department of Surgical SciencesJohn Radcliffe HospitalUniversity of OxfordOxfordUK
| | - A. Bushell
- Transplantation Research Immunology GroupNuffield Department of Surgical SciencesJohn Radcliffe HospitalUniversity of OxfordOxfordUK
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Tan C, Halushka M, Rodriguez E. Pathology of Cardiac Transplantation. Cardiovasc Pathol 2016. [DOI: 10.1016/b978-0-12-420219-1.00016-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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9
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The natural history of biopsy-negative rejection after heart transplantation. J Transplant 2013; 2013:236720. [PMID: 24490053 PMCID: PMC3893856 DOI: 10.1155/2013/236720] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 11/09/2013] [Accepted: 11/23/2013] [Indexed: 11/17/2022] Open
Abstract
Purpose. The most recent International Society for Heart and Lung Transplantation (ISHLT) biopsy scale classifies cellular and antibody-mediated rejections. However, there are cases with acute decline in left ventricular ejection fraction (LVEF ≤ 45%) but no evidence of rejection on biopsy. Characteristics and treatment response of this biopsy negative rejection (BNR) have yet to be elucidated. Methods. Between 2002 and 2012, we found 12 cases of BNR in 11 heart transplant patients as previously defined. One of the 11 patients was treated a second time for BNR. Characteristics and response to treatment were noted. Results. 12 cases (of 11 patients) were reviewed and 11 occurred during the first year after transplant. 8 cases without heart failure symptoms were treated with an oral corticosteroids bolus and taper or intravenous immunoglobulin. Four cases with heart failure symptoms were treated with thymoglobulin, intravenous immunoglobulin, and intravenous methylprednisolone followed by an oral corticosteroids bolus and taper. Overall, 7 cases resulted in return to normal left ventricular function within a mean of 14 ± 10 days from the initial biopsy. Conclusion. BNR includes cardiac dysfunction and can be a severe form of rejection. Characteristics of these cases of rejection are described with most cases responding to appropriate therapy.
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Early Postoperative Left Ventricular Function by Echocardiographic Strain is a Predictor of 1-Year Mortality in Heart Transplant Recipients. J Am Soc Echocardiogr 2012; 25:1007-14. [DOI: 10.1016/j.echo.2012.05.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Indexed: 11/20/2022]
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Holweg CTJ, Potena L, Luikart H, Yu T, Berry GJ, Cooke JP, Valantine HA, Mocarski ES. Identification and classification of acute cardiac rejection by intragraft transcriptional profiling. Circulation 2011; 123:2236-43. [PMID: 21555702 DOI: 10.1161/circulationaha.109.913921] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Treatment of acute rejection (AR) in heart transplantation relies on histopathological grading of endomyocardial biopsies according to International Society for Heart and Lung Transplantation guidelines. Intragraft gene expression profiling may be a way to complement histological evaluation. METHODS AND RESULTS Transcriptional profiling was performed on 26 endomyocardial biopsies, and expression patterns were compared with the 1990 International Society for Heart and Lung Transplantation AR grades. Importantly, transcriptional profiles from settings with an equivalent AR grade appeared the same. In addition, grade 0 profiles could not be distinguished from 1A profiles, and grade 3A profiles could not be distinguished from 3B profiles. Comparing the AR groupings (0+1A, 1B, and 3A+3B), 0+1A showed more striking differences from 1B than from 3A+3B. When these findings were extrapolated to the 2005 revised guidelines, the combination of 1A and 1B into a single category (1R) appears to have brought together endomyocardial biopsies with different underlying processes that are not evident from histological evaluation. Grade 1B was associated with upregulated immune response genes, as 1 categorical distinction from grade 1A. Although grade 1B was distinct from the clinically relevant AR grades 3A and 3B, all of these grades shared a small number of overlapping pathways consistent with common physiological underpinnings. CONCLUSION The gene expression similarities and differences identified here in different AR settings have the potential to revise the clinical perspective on acute graft rejection, pending the results of larger studies.
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Affiliation(s)
- Cécile T J Holweg
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Zeglen S, Zakliczynski M, Wozniak-Grygiel E, Nozynski J, Laszewska A, Wojarski J, Wojnicz R, Przybylski R, Kucewicz-Czech E, Zembala M. Mixed Cellular and Humoral Acute Rejection in Elective Biopsies From Heart Transplant Recipients. Transplant Proc 2009; 41:3202-5. [DOI: 10.1016/j.transproceed.2009.08.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Heart retransplantation for undiagnosed severe acute cellular rejection. COR ET VASA 2008. [DOI: 10.33678/cor.2008.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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