1
|
Management of Stroke in Patients with Left Ventricular Assist Devices. J Stroke Cerebrovasc Dis 2020; 29:105166. [PMID: 33066940 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105166] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION The number of patients with left ventricular assist devices (LVAD) is rapidly growing in industrialized countries. While cerebrovascular events comprise a significant complication, data on stroke etiology, clinical management and functional outcome are scarce. METHODS Consecutive LVAD patients with ischemic or hemorrhagic stroke receiving treatment at an university stroke center between 2010 and 2018 were included into an institutional registry. Clinical characteristics, causes, management and functional outcome of stroke occurring within this cohort are reported. Acceptable functional outcome was defined as mRS 0-3. RESULTS N = 30 acute strokes occurred in 20 patients (77% ischemic, 23% hemorrhagic, mean age 57 ± 13 years, 10% female, 8 patients (40%) had more than one event). 87% of all events happened with non-pulsatile devices, on average 9 (IQR 3-22) months after the implantation. All patients used oral anticoagulation with a Vitamin-K antagonist in combination with anti-platelets. The international normalized ratio (INR)-values were outside the therapeutic range in 39% of ischemic strokes and in 57% of hemorrhagic strokes. Ischemic strokes were predominantly of cardioembolic origin (92%) and of mild to moderate clinical severity (median NIHSS 6 (IQR 4-10). None qualified to receive intravenous thrombolysis or intra-arterial endovascular therapy. 61% of IS-patients showed an acceptable functional outcome after three months. 4/7 patients with hemorrhagic stroke received immediate reversal of anticoagulation without any thrombotic complications. CONCLUSION The majority of LVAD patients with ischemic stroke had an acceptable functional outcome after three months. Future clinical research is warranted to improve therapeutic strategies for acute care and stroke prevention.
Collapse
|
2
|
Aleksova N, Alba AC, Fan CPS, Mueller B, Mielniczuk LM, Davies RA, Stadnick E, Ross HJ, Chih S. Impact of organ prioritization for immunologic sensitization and waiting times for heart transplantation. J Heart Lung Transplant 2019; 38:285-294. [DOI: 10.1016/j.healun.2018.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 11/26/2018] [Accepted: 12/14/2018] [Indexed: 01/06/2023] Open
|
3
|
Calculated panel-reactive antibody predicts outcomes on the heart transplant waiting list. J Heart Lung Transplant 2017; 36:787-796. [DOI: 10.1016/j.healun.2017.02.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 02/07/2017] [Accepted: 02/15/2017] [Indexed: 11/24/2022] Open
|
4
|
Ross HJ, Law Y, Book WM, Broberg CS, Burchill L, Cecchin F, Chen JM, Delgado D, Dimopoulos K, Everitt MD, Gatzoulis M, Harris L, Hsu DT, Kuvin JT, Martin CM, Murphy AM, Singh G, Spray TL, Stout KK. Transplantation and Mechanical Circulatory Support in Congenital Heart Disease. Circulation 2016; 133:802-20. [DOI: 10.1161/cir.0000000000000353] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
5
|
Stout KK, Broberg CS, Book WM, Cecchin F, Chen JM, Dimopoulos K, Everitt MD, Gatzoulis M, Harris L, Hsu DT, Kuvin JT, Law Y, Martin CM, Murphy AM, Ross HJ, Singh G, Spray TL. Chronic Heart Failure in Congenital Heart Disease. Circulation 2016; 133:770-801. [DOI: 10.1161/cir.0000000000000352] [Citation(s) in RCA: 219] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
6
|
LVAD implant as a bridge to heart transplantation is associated with allosensitization as measured by single antigen bead assay. Transplantation 2014; 96:324-30. [PMID: 23743727 DOI: 10.1097/tp.0b013e3182985371] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Left ventricular assist devices (LVAD) as a bridge (BTT) to heart transplantation (HTX) may be limited by the formation of anti-human leukocyte antigen antibodies. Whether sensitization occurs with continuous axial flow LVAD implant as assessed by single antigen bead (SAB) assay is unknown. METHODS Cytotoxic panel-reactive antibody (PRA) and SAB assays were analyzed in HTX recipients undergoing LVAD implant as a BTT. Sensitization was defined as peak anti-human leukocyte antigen antibody values of more than 2000 mean fluorescence intensity because these values have been found to correlate with flow cytometric crossmatch results. RESULTS LVADs were implanted as BTT in 30 patients. There were 7% (2 of 30) of patients before LVAD implant and no patients after LVAD implant with PRA more than 10%. However, 20% (6 of 30) of patients before LVAD and 53% (16 of 30) after LVAD were sensitized as measured by SAB (P=0.024). At HTX, 47% (14 of 30) of patients remained sensitized. A positive virtual crossmatch was observed in 28% (4 of 14) of the sensitized patients at HTX. There was no difference between the sensitized and nonsensitized groups (P>0.4 for all) in usage of blood products (6411 vs. 6339 units) and time to HTX (28,663 vs. 25,748 days), and 1 year after HTX, there were no differences in rejection (total rejection score 0.30 vs. 0.37) and survival (93% vs. 88%). CONCLUSION Allosensitization after LVAD is common despite cytotoxic PRA being negative. One year after HTX, this sensitization does not translate into increased acute cellular or antibody-mediated rejection or reduced survival.
Collapse
|
7
|
MacIver J, Rao V, Ross HJ. Quality of life for patients supported on a left ventricular assist device. Expert Rev Med Devices 2014; 8:325-37. [DOI: 10.1586/erd.11.9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
8
|
Potena L, Bontadini A, Iannelli S, Fruet F, Leone O, Barberini F, Borgese L, Manfredini V, Masetti M, Magnani G, Fallani F, Grigioni F, Branzi A. Occurrence of Fatal and Nonfatal Adverse Outcomes after Heart Transplantation in Patients with Pretransplant Noncytotoxic HLA Antibodies. J Transplant 2013; 2013:519680. [PMID: 23984043 PMCID: PMC3745955 DOI: 10.1155/2013/519680] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 06/09/2013] [Indexed: 11/17/2022] Open
Abstract
HLA antibodies (HLA ab) in transplant candidates have been associated with poor outcome. However, clinical relevance of noncytotoxic antibodies after heart transplant (HT) is controversial. By using a Luminex-based HLA screening, we retested pretransplant sera from HT recipients testing negative for cytotoxic HLA ab and for prospective crossmatch. Out of the 173 consecutive patients assayed (52 ± 13y; 16% females; 47% ischemic etiology), 32 (18%) showed pretransplant HLA ab, and 12 (7%) tested positive against both class I and class II HLA. Recipients with any HLA ab had poorer survival than those without (65 ± 9 versus 82 ± 3%; P = 0.02), accounting for a doubled independent mortality risk (P = 0.04). In addition, HLA-ab detection was associated with increased prevalence of early graft failure (35 versus 15%; P = 0.05) and late cellular rejection (29 versus 11%; P = 0.03). Of the subgroup of 37 patients suspected for antibody mediated rejection (AMR), the 9 with pretransplant HLA ab were more likely to display pathological AMR grade 2 (P = 0.04). By an inexpensive, luminex-based, HLA-screening assay, we were able to detect non-cytotoxic HLA ab predicting fatal and nonfatal adverse outcomes after heart transplant. Allocation strategies and desensitization protocols need to be developed and prospectively tested in these patients.
Collapse
Affiliation(s)
- Luciano Potena
- Cardiovascular Department, Academic Hospital S. Orsola-Malpighi, University of Bologna, Building 21, Via Massarenti 9, 40138 Bologna, Italy
| | - Andrea Bontadini
- Immunogenetics Unit, Transfusion Service, Academic Hospital S. Orsola-Malpighi, University of Bologna, Italy
| | - Sandra Iannelli
- Immunogenetics Unit, Transfusion Service, Academic Hospital S. Orsola-Malpighi, University of Bologna, Italy
| | - Fiorenza Fruet
- Immunogenetics Unit, Transfusion Service, Academic Hospital S. Orsola-Malpighi, University of Bologna, Italy
| | - Ornella Leone
- Pathology Department, Academic Hospital S. Orsola-Malpighi, University of Bologna, Italy
| | - Francesco Barberini
- Cardiovascular Department, Academic Hospital S. Orsola-Malpighi, University of Bologna, Building 21, Via Massarenti 9, 40138 Bologna, Italy
| | - Laura Borgese
- Cardiovascular Department, Academic Hospital S. Orsola-Malpighi, University of Bologna, Building 21, Via Massarenti 9, 40138 Bologna, Italy
| | - Valentina Manfredini
- Cardiovascular Department, Academic Hospital S. Orsola-Malpighi, University of Bologna, Building 21, Via Massarenti 9, 40138 Bologna, Italy
| | - Marco Masetti
- Cardiovascular Department, Academic Hospital S. Orsola-Malpighi, University of Bologna, Building 21, Via Massarenti 9, 40138 Bologna, Italy
| | - Gaia Magnani
- Cardiovascular Department, Academic Hospital S. Orsola-Malpighi, University of Bologna, Building 21, Via Massarenti 9, 40138 Bologna, Italy
| | - Francesco Fallani
- Cardiovascular Department, Academic Hospital S. Orsola-Malpighi, University of Bologna, Building 21, Via Massarenti 9, 40138 Bologna, Italy
| | - Francesco Grigioni
- Cardiovascular Department, Academic Hospital S. Orsola-Malpighi, University of Bologna, Building 21, Via Massarenti 9, 40138 Bologna, Italy
| | - Angelo Branzi
- Cardiovascular Department, Academic Hospital S. Orsola-Malpighi, University of Bologna, Building 21, Via Massarenti 9, 40138 Bologna, Italy
| |
Collapse
|
9
|
Lalonde SD, Alba AC, Rigobon A, Ross HJ, Delgado DH, Billia F, McDonald M, Cusimano RJ, Yau TM, Rao V. Clinical Differences Between Continuous Flow Ventricular Assist Devices:
A Comparison Between HeartMate II and HeartWare HVAD. J Card Surg 2013; 28:604-10. [DOI: 10.1111/jocs.12158] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Spencer D. Lalonde
- Heart Failure/Transplant Program, Peter Munk Cardiac Centre, Toronto General Hospital; University Health Network; Toronto Ontario Canada
| | - Ana C. Alba
- Heart Failure/Transplant Program, Peter Munk Cardiac Centre, Toronto General Hospital; University Health Network; Toronto Ontario Canada
| | - Alanna Rigobon
- Heart Failure/Transplant Program, Peter Munk Cardiac Centre, Toronto General Hospital; University Health Network; Toronto Ontario Canada
| | - Heather J. Ross
- Heart Failure/Transplant Program, Peter Munk Cardiac Centre, Toronto General Hospital; University Health Network; Toronto Ontario Canada
| | - Diego H. Delgado
- Heart Failure/Transplant Program, Peter Munk Cardiac Centre, Toronto General Hospital; University Health Network; Toronto Ontario Canada
| | - Filio Billia
- Heart Failure/Transplant Program, Peter Munk Cardiac Centre, Toronto General Hospital; University Health Network; Toronto Ontario Canada
| | - Michael McDonald
- Heart Failure/Transplant Program, Peter Munk Cardiac Centre, Toronto General Hospital; University Health Network; Toronto Ontario Canada
| | - Robert J. Cusimano
- Heart Failure/Transplant Program, Peter Munk Cardiac Centre, Toronto General Hospital; University Health Network; Toronto Ontario Canada
| | - Terrence M. Yau
- Heart Failure/Transplant Program, Peter Munk Cardiac Centre, Toronto General Hospital; University Health Network; Toronto Ontario Canada
| | - Vivek Rao
- Heart Failure/Transplant Program, Peter Munk Cardiac Centre, Toronto General Hospital; University Health Network; Toronto Ontario Canada
| |
Collapse
|
10
|
Affiliation(s)
- Jane Maciver
- Divisions of Cardiology and Transplantation, Toronto General Hospital, Toronto, Ontario, Canada
| | | |
Collapse
|
11
|
A sensitive approach. J Heart Lung Transplant 2012; 31:1042-3. [PMID: 22784934 DOI: 10.1016/j.healun.2012.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 05/14/2012] [Accepted: 05/15/2012] [Indexed: 11/22/2022] Open
|
12
|
Picascia A, Grimaldi V, Zullo A, Infante T, Maiello C, Crudele V, Sessa M, Mancini FP, Napoli C. Current Concepts in Histocompatibility During Heart Transplant. EXP CLIN TRANSPLANT 2012; 10:209-18. [DOI: 10.6002/ect.2011.0185] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
13
|
Abstract
PURPOSE OF REVIEW With increasing utilization of assist devices and adoption of calculated panel-reactive antibody (cPRA), the number of presensitized patients being listed for heart transplantation is increasing. An effort to standardize identification and management of such patients is paramount and recently initiated in the heart transplant community. The current review describes the basic concepts of presensitization and details the most relevant work including the latest advancements in this area. RECENT FINDINGS More sensitive techniques in identifying presensitized patients have posed challenges in understanding the clinical relevance and implications of such testing. cPRA has been shown to benefit presensitized heart transplant patients. De-sensitization strategies have never been studied in a large clinical trial setting but a combination of plasmapheresis and intravenous immunoglobulin has been shown to be beneficial in small studies. Long-term positive outcomes of de-sensitization have been recently reported. Newer agents like alemtuzumab, bortezomib and complement inhibitors have been reported in case reports and series with promising results as de-sensitization strategy. SUMMARY Data specific to strategies and therapies in heart transplantation are sparse and most knowledge stems from other organ transplantation. Consensus efforts to standardize care and also advance research in this area were initiated recently with hope for improving care for these patients.
Collapse
|
14
|
West LJ. Toward Donor Allocation Equitability for High Immunological Risk Patients Awaiting Transplantation: “4S 4 HI-cPRA”. Can J Cardiol 2011; 27:677-8. [DOI: 10.1016/j.cjca.2011.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Accepted: 10/09/2011] [Indexed: 11/26/2022] Open
|
15
|
Montgomery RA, Cozzi E, West LJ, Warren DS. Humoral immunity and antibody-mediated rejection in solid organ transplantation. Semin Immunol 2011; 23:224-34. [PMID: 21958960 DOI: 10.1016/j.smim.2011.08.021] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Accepted: 08/24/2011] [Indexed: 02/07/2023]
Abstract
The humoral arm of the immune system provides robust protection against extracellular pathogens via the production of antibody molecules that neutralize or facilitate the destruction of microorganisms. However, the humoral immune system also provides a significant barrier to solid organ transplantation due to the antibody-mediated recognition of non-self proteins and carbohydrates expressed on transplanted organs. Historically, the presence of donor-specific antibodies (DSA) that recognize donor HLA molecules, incompatible ABO blood group antigens and other endothelial or xenogeneic antigens was considered a contraindication to transplantation. However, recent advances in antibody testing and immunosuppressive therapies have made it possible to cross certain antibody barriers successfully. In this article, we review our current understanding of antibody-mediated processes in solid organ transplantation and discuss the clinically available treatment options for preventing and treating antibody-mediated rejection.
Collapse
Affiliation(s)
- Robert A Montgomery
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | |
Collapse
|
16
|
McKelvie RS, Moe GW, Cheung A, Costigan J, Ducharme A, Estrella-Holder E, Ezekowitz JA, Floras J, Giannetti N, Grzeslo A, Harkness K, Heckman GA, Howlett JG, Kouz S, Leblanc K, Mann E, O'Meara E, Rajda M, Rao V, Simon J, Swiggum E, Zieroth S, Arnold JMO, Ashton T, D'Astous M, Dorian P, Haddad H, Isaac DL, Leblanc MH, Liu P, Sussex B, Ross HJ. The 2011 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Sleep Apnea, Renal Dysfunction, Mechanical Circulatory Support, and Palliative Care. Can J Cardiol 2011; 27:319-38. [DOI: 10.1016/j.cjca.2011.03.011] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 03/15/2011] [Indexed: 10/18/2022] Open
|
17
|
On solid-phase antibody assays. J Heart Lung Transplant 2010; 29:1207-9. [DOI: 10.1016/j.healun.2010.06.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 06/14/2010] [Accepted: 06/30/2010] [Indexed: 11/15/2022] Open
|