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Fida N, Eagar TN, Yun AN, Rogers AW, Nguyen DT, Graviss EA, Ishaq F, DiPaola NR, Kim J, Janardhana G, Kassi M, Yousefzai R, Suarez EE, Bhimaraj A, Krisl JC, Guha A. Effectiveness of combined plasma cell therapy and costimulation blockade based desensitization regimen in heart transplant candidates. Clin Transplant 2024; 38:e15249. [PMID: 38369810 DOI: 10.1111/ctr.15249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 12/22/2023] [Accepted: 01/17/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Desensitization is one of the strategies to reduce antibodies and facilitate heart transplantation in highly sensitized patients. We describe our center's desensitization experience with combination of plasma cell (PC) depletion therapy (with proteasome inhibitor or daratumumab) and costimulation blockade (with belatacept). METHODS We reviewed five highly sensitized patients who underwent desensitization therapy with plasma cell depletion and costimulation blockade. We evaluated the response to therapy by measuring the changes in cPRA, average MFI, and number of positive beads > 5000MFI. RESULTS Five patients, mean age of 56 (37-66) years with average cPRA of 98% at 5000 MFI underwent desensitization therapy. After desensitization, mean cPRA decreased from 98% to 70% (p = .09), average number of beads > 5000 MFI decreased from 59 to 37 (p = .15), and average MFI of beads > 5000 MFI decreased from 16713 to 13074 (p = .26). CONCLUSION Combined PC depletion and CoB could be a reasonable strategy for sustained reduction in antibodies in highly sensitized patients being listed for heart transplantation.
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Affiliation(s)
- Nadia Fida
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Todd N Eagar
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, USA
| | - Allison N Yun
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas, USA
| | - Alex W Rogers
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Institute for Academic Medicine, Houston Methodist Research Institute, Houston, Texas, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Institute for Academic Medicine, Houston Methodist Research Institute, Houston, Texas, USA
| | - Farhan Ishaq
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Nicholas R DiPaola
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, USA
| | - Ju Kim
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Gorthi Janardhana
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Mahwash Kassi
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Rayan Yousefzai
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Eric E Suarez
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Arvind Bhimaraj
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Jill C Krisl
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas, USA
| | - Ashrith Guha
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
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2
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DeFilippis EM, Ji Z, Masotti M, Maharaj V, Alexy T, Kittleson MM, Cogswell R. Association between calculated panel reactive antibody and waitlist outcomes in the 2018 heart allocation system. J Heart Lung Transplant 2023; 42:1469-1477. [PMID: 37268050 DOI: 10.1016/j.healun.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/09/2023] [Accepted: 05/25/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND The impact of heart transplant (HT) waitlist candidate sensitization on waitlist outcomes in the US is unknown. METHODS Adult waitlist outcomes in OPTN (October 2018-September 2022) by calculated panel reactive antibody (cPRA) were modeled to identify thresholds of clinical significance. The primary outcome was the rate of HT by cPRA category (low: 0-35, middle: >35-90, high: >90) assessed using multivariable competing risk analysis (compete: waitlist removal for death or clinical deterioration). The secondary outcome was waitlist removal for death or clinical deterioration. RESULTS The elevated cPRA categories were associated with lower rates of HT. Candidates in the middle (35-90) and high cPRA categories (>90) had an adjusted 24% lower rate (hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.80-0.92) and 61% lower rate (HR 0.39 95% CI. 0.33-0.47) of HT than the lowest category, respectively. Waitlist candidates in the high cPRA category listed in the top acuity strata (Statuses 1, 2) had increased rates of delisting for death or deterioration compared to those in the low cPRA category (adjusted HR 2.9, 95% CI 1.5-5.5), however, elevated cPRA (middle, high) was not associated with an increased rate of death and delisting when the cohort was considered as a whole. CONCLUSIONS Elevated cPRA was associated with reduced rates of HT across all waitlist acuity tiers. Among HT waitlist candidates listed at the top acuity strata, the high cPRA category was associated with increased rates of delisting due to death or deterioration. Elevated cPRA may require consideration for critically ill candidates under continuous allocation.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Ziyu Ji
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Maria Masotti
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Valmiki Maharaj
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Tamas Alexy
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rebecca Cogswell
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota.
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3
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Kittleson MM. Management of the sensitized heart transplant candidate. Curr Opin Organ Transplant 2023; 28:362-369. [PMID: 37678171 DOI: 10.1097/mot.0000000000001096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
PURPOSE OF REVIEW For sensitized heart transplant candidates who have antibodies to human leukocyte antigens (HLA), finding a suitable donor can be challenging and can lead to adverse waitlist outcomes. In recent years, the number of sensitized patients awaiting heart transplantation has increased likely due to the use of durable and mechanical circulatory support as well as increasing number of candidates with underlying congenital heart disease. RECENT FINDINGS Advances in the assessment of HLA antibodies allow for identification of heart transplant candidates who may benefit from desensitization strategies to widen the donor pool and mitigate the risk of adverse posttransplant outcomes. SUMMARY Antibody sensitization is a barrier to successful heart transplantation and strategies to identify sensitized patients, stratify their risk, and mitigate this risk through desensitization is crucial to optimize the quality of life and survival of HT recipients.
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Affiliation(s)
- Michelle M Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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4
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Vaidya AS, Lee ES, Kawaguchi ES, DePasquale EC, Pandya KA, Fong MW, Nattiv J, Villalon S, Sertic A, Cochran A, Ackerman MA, Melendrez M, Cartus R, Johnston KA, Lee R, Wolfson AM. Effect of the UNOS policy change on rates of rejection, infection, and hospital readmission following heart transplantation. J Heart Lung Transplant 2023; 42:1415-1424. [PMID: 37211332 DOI: 10.1016/j.healun.2023.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 04/04/2023] [Accepted: 05/15/2023] [Indexed: 05/23/2023] Open
Abstract
BACKGROUND The 2018 adult heart allocation policy sought to improve waitlist risk stratification, reduce waitlist mortality, and increase organ access. This system prioritized patients at greatest risk for waitlist mortality, especially individuals requiring temporary mechanical circulatory support (tMCS). Posttransplant complications are significantly higher in patients on tMCS before transplantation, and early posttransplant complications impact long-term mortality. We sought to determine if policy change affected early posttransplant complication rates of rejection, infection, and hospitalization. METHODS We included all adult, heart-only, single-organ heart transplant recipients from the UNOS registry with pre-policy (PRE) individuals transplanted between November 1, 2016, and October 31, 2017, and post-policy (POST) between November 1, 2018, and October 31, 2019. We used a multivariable logistic regression analysis to assess the effect of policy change on posttransplant rejection, infection, and hospitalization. Two COVID-19 eras (2019-2020, 2020-2021) were included in our analysis. RESULTS The majority of baseline characteristics were comparable between PRE and POST era recipients. The odds of treated rejection (p = 0.8), hospitalization (p = 0.69), and hospitalization due to rejection (p = 0.76) and infection (p = 0.66) were similar between PRE and POST eras; there was a trend towards reduced odds of rejection (p = 0.08). In both COVID eras, there was a clear reduction in rejection and treated rejection with no effect on hospitalization for rejection or infection. Odds of all-cause hospitalization was increased in both COVID eras. CONCLUSIONS The UNOS policy change improves access to heart transplantation for higher acuity patients without increasing early posttransplant rates of treated rejection or hospitalization for rejection or infection, factors which portend risk for long-term posttransplant mortality.
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Affiliation(s)
- Ajay S Vaidya
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California.
| | - Emily S Lee
- Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Eric S Kawaguchi
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Eugene C DePasquale
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kruti A Pandya
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Michael W Fong
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jonathan Nattiv
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Sylvia Villalon
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Ashley Sertic
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Ashley Cochran
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Mary Alice Ackerman
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Marie Melendrez
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Rachel Cartus
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Kori Ann Johnston
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Raymond Lee
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Aaron M Wolfson
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
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5
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Goldberg JF, Truby LK, Agbor-Enoh S, Jackson AM, deFilippi CR, Khush KK, Shah P. Selection and Interpretation of Molecular Diagnostics in Heart Transplantation. Circulation 2023; 148:679-694. [PMID: 37603604 PMCID: PMC10449361 DOI: 10.1161/circulationaha.123.062847] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
The number of heart transplants performed annually in the United States and worldwide continues to increase, but there has been little change in graft longevity and patient survival over the past 2 decades. The reference standard for diagnosis of acute cellular and antibody-mediated rejection includes histologic and immunofluorescence evaluation of endomyocardial biopsy samples, despite invasiveness and high interrater variability for grading histologic rejection. Circulating biomarkers and molecular diagnostics have shown substantial predictive value in rejection monitoring, and emerging data support their use in diagnosing other posttransplant complications. The use of genomic (cell-free DNA), transcriptomic (mRNA and microRNA profiling), and proteomic (protein expression quantitation) methodologies in diagnosis of these posttransplant outcomes has been evaluated with varying levels of evidence. In parallel, growing knowledge about the genetically mediated immune response leading to rejection (immunogenetics) has enhanced understanding of antibody-mediated rejection, associated graft dysfunction, and death. Antibodies to donor human leukocyte antigens and the technology available to evaluate these antibodies continues to evolve. This review aims to provide an overview of biomarker and immunologic tests used to diagnose posttransplant complications. This includes a discussion of pediatric heart transplantation and the disparate rates of rejection and death experienced by Black patients receiving a heart transplant. This review describes diagnostic modalities that are available and used after transplant and the landscape of future investigations needed to enhance patient outcomes after heart transplantation.
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Affiliation(s)
- Jason F Goldberg
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, VA (J.F.G., C.R.d., P.S.)
- Department of Pediatrics, Inova L.J. Murphy Children's Hospital, Falls Church, VA (J.F.G.)
| | - Lauren K Truby
- Department of Medicine, University of Texas Southwestern, Dallas (L.K.T.)
| | - Sean Agbor-Enoh
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD (S.A.-E.)
- Applied Precision Genomics, National Heart, Lung and Blood Institute, Bethesda, MD (S.A.-E.)
| | - Annette M Jackson
- Department of Surgery, Duke University School of Medicine, Durham, NC (A.M.J.)
| | - Christopher R deFilippi
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, VA (J.F.G., C.R.d., P.S.)
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, CA (K.K.K.)
| | - Palak Shah
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, VA (J.F.G., C.R.d., P.S.)
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6
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DeFilippis EM, Kransdorf EP, Jaiswal A, Zhang X, Patel J, Kobashigawa JA, Baran DA, Kittleson MM. Detection and management of HLA sensitization in candidates for adult heart transplantation. J Heart Lung Transplant 2023; 42:409-422. [PMID: 36631340 DOI: 10.1016/j.healun.2022.12.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 12/13/2022] [Accepted: 12/17/2022] [Indexed: 12/28/2022] Open
Abstract
Heart transplantation (HT) remains the preferred therapy for patients with advanced heart failure. However, for sensitized HT candidates who have antibodies to human leukocyte antigens , finding a suitable donor can be challenging and can lead to adverse waitlist outcomes. In recent years, the number of sensitized patients awaiting HT has increased likely due to the use of durable and mechanical circulatory support as well as increasing number of candidates with underlying congenital heart disease. This State-of-the-Art review discusses the assessment of human leukocyte antigens antibodies, potential desensitization strategies including mechanisms of action and specific protocols, the approach to a potential donor including the use of complement-dependent cytotoxicity, flow cytometry, and virtual crossmatches, and peritransplant induction management.
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Affiliation(s)
- Ersilia M DeFilippis
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Abhishek Jaiswal
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Xiaohai Zhang
- HLA and Immunogenetics Laboratory, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David A Baran
- Cleveland Clinic, Heart Vascular and Thoracic Institute, Weston, Florida
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7
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Rao RA, Kransdorf EP, Patel JK, Kobashigawa JA, Kittleson MM. How to Approach HLA Sensitization in Heart Transplant Candidates. JACC: HEART FAILURE 2023; 11:469-475. [PMID: 37019560 DOI: 10.1016/j.jchf.2023.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/16/2022] [Accepted: 01/10/2023] [Indexed: 04/05/2023]
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8
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van den Hoogen P, Huibers MMH, van den Dolder FW, de Weger R, Siera-de Koning E, Oerlemans MIF, de Jonge N, van Laake LW, Doevendans PA, Sluijter JPG, Vink A, de Jager SCA. Elevated Plasma Immunoglobulin Levels Prior to Heart Transplantation Are Associated with Poor Post-Transplantation Survival. BIOLOGY 2022; 12:biology12010061. [PMID: 36671753 PMCID: PMC9855413 DOI: 10.3390/biology12010061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/20/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022]
Abstract
Cardiac allograft vasculopathy (CAV) and antibody-mediated rejection are immune-mediated, long-term complications that jeopardize graft survival after heart transplantation (HTx). Interestingly, increased plasma levels of immunoglobulins have been found in end-stage heart failure (HF) patients prior to HTx. In this study, we aimed to determine whether increased circulating immunoglobulin levels prior to transplantation are associated with poor post-HTx survival. Pre-and post-HTx plasma samples of 36 cardiac transplant recipient patients were used to determine circulating immunoglobulin levels. In addition, epicardial tissue was collected to determine immunoglobulin deposition in cardiac tissue and assess signs and severity of graft rejection. High levels of IgG1 and IgG2 prior to HTx were associated with a shorter survival post-HTx. Immunoglobulin deposition in cardiac tissue was significantly elevated in patients with a survival of less than 3 years. Patients with high plasma IgG levels pre-HTx also had significantly higher plasma levels after HTx. Furthermore, high pre-HTX levels of IgG1 and IgG2 levels were also significantly increased in patients with inflammatory infiltrate in CAV lesions. Altogether the results of this proof-of-concept study suggest that an activated immune response prior to transplantation negatively affects graft survival.
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Affiliation(s)
- Patricia van den Hoogen
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Circulatory Health Laboratory, Regenerative Medicine Center, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Manon M. H. Huibers
- Department of Pathology, Circulatory Health Laboratory, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
- Department of Genetics, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Floor W. van den Dolder
- Department of Pathology, Circulatory Health Laboratory, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Roel de Weger
- Department of Pathology, Circulatory Health Laboratory, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Erica Siera-de Koning
- Department of Pathology, Circulatory Health Laboratory, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Marish I. F. Oerlemans
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Nicolaas de Jonge
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Linda W. van Laake
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Pieter A. Doevendans
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Netherlands Heart Institute (NLHI), 3511 EP Utrecht, The Netherlands
- Centraal Militair Hospitaal (CMH), 3584 EZ Utrecht, The Netherlands
| | - Joost. P. G. Sluijter
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Circulatory Health Laboratory, Regenerative Medicine Center, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Aryan Vink
- Department of Pathology, Circulatory Health Laboratory, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Saskia C. A. de Jager
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Circulatory Health Laboratory, Regenerative Medicine Center, Utrecht University, 3584 CX Utrecht, The Netherlands
- Laboratory of Translational Immunology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Correspondence:
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9
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Yu SH, Chou HW, Wang CH, Tsao CI, Fu HY, Chen KPH, Chi NH, Huang SC, Chou NK, Hsu RB, Yu HY, Lin JW, Chen YS. Impact of duration of mechanical support on heart transplantation: Hasty transplantation may not have a good long-term outcome. Clin Transplant 2022; 36:e14746. [PMID: 35751454 DOI: 10.1111/ctr.14746] [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: 03/30/2022] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Mechanical circulatory support (MCS) has been widely utilized in critically ill cardiac transplant candidates. Few studies have investigated the impact of duration of MCS before heart transplantation (HTx) on long-term patient survival. METHODS A retrospective HTx database was reviewed between 2009 and 2019. Patients who did not or did undergo MCS before HTx were categorized into two groups: (1) A (did not) and (2) B (did), respectively. A receiver operating characteristic (ROC) curve was plotted to assess the cutoff level of MCS duration before HTx in evaluating 5-year survival. RESULT A total of 270 HTx patients (group A: 120, group B: 150) were analyzed. Group B patients had a higher percentage of blood type O, a higher incidence of resuscitation, a shorter listing duration, and a higher likelihood of having United Network for Organ Sharing (UNOS) 1A status than group A. The ROC curve revealed 24 days as a good cut-off level for determining the best MCS before HTx timing. Group B was categorized into two subgroups: (1) B1 (MCS < 24 days, n = 65) and (2) B2 (MCS > 24 days, n = 85). B2 had a higher incidence of cardiopulmonary resuscitation (CPR), hemodialysis, longer waiting time after MCS, and better ventricular assist device implantation than B1. However, the survival curves showed that B1 outcomes were significantly worse than in groups A and B2. Groups A and B2 had similar survival curves without an increased incidence of infection. CONCLUSION The preliminary data demonstrated that a longer duration of MCS may be associated with better outcomes than urgent HTx.
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Affiliation(s)
- Sz-Han Yu
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Heng-Wen Chou
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Hsien Wang
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chuan-I Tsao
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsun-Yi Fu
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Nai-Hsin Chi
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Chien Huang
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Nai-Kuan Chou
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ron-Bin Hsu
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsi-Yu Yu
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Jou-Wei Lin
- Cardiology, Internal Medicine, National Taiwan University Hospital Yunlin Branch, Douliu, Taiwan
| | - Yih-Sharng Chen
- Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.,Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan.,Surgery, School of Medicine, National Taiwan University, Taipei, Taiwan
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10
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Cabrera-Rubio I, Canteli Álvarez Á, Castrillo Bustamante C, Burgos Palacios V, Ruiz Lera M, Cobo Belaustegui M, Llano Cardenal MF, González-Vílchez F. Sensitization during short-term mechanical circulatory support. Determinants, therapeutic management, and outcomes after heart transplant. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:251-260. [PMID: 33863685 DOI: 10.1016/j.rec.2021.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 01/21/2021] [Indexed: 06/12/2023]
Abstract
INTRODUCTION AND OBJECTIVES The development of human-leukocyte antigen antibodies is a well-known adverse effect of the use of long-term ventricular assist devices (VADs). The aim of this study was to determine the incidence of sensitization during short-term mechanical circulatory support with VAD (CentriMag), its determinants, and its impact on posttransplant outcomes. METHODS We performed a retrospective review of patients who were bridged to transplant with short-term VAD from 2009 to 2019. Sensitization was defined as a calculated panel-reactive antibody> 10%. The endpoints included overall survival and rejection-free survival. RESULTS A total of 89 patients (median age 56.0 [interquartile range, 50.0-59.9] years, 16.8% female) received a short-term VAD as a bridge to transplant. The median duration of support was 23.6 [interquartile range, 16.6-35.0] days. Eleven patients (12.4%) became sensitized during support. The only factor significantly associated with sensitization was female sex (OR, 8.67; 95%CI, 1.93-38.8; P=.005). Of the 89 patients, 21 patients died during support; 68 patients underwent heart transplant. After a mean follow-up of 49.6 ±31.2 months, 8 patients (11.8%) died and 20 (29.4%) had at least 1 rejection episode. On multivariate analysis, sensitization was an independent predictor of acute rejection (HR, 3.64; 95%CI, 1.42-9.33; P=.007), with a nonstatistically significant trend to higher mortality (HR, 4.07; 95%CI, 0.96-17.3; P=.057). CONCLUSIONS Sensitization with short-term VADs can occur and is significantly associated with female sex and with rejection. Sensitization also showed a nonstatistically significant trend to higher mortality.
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Affiliation(s)
- Indira Cabrera-Rubio
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain.
| | - Ángela Canteli Álvarez
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Cristina Castrillo Bustamante
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Virginia Burgos Palacios
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Marta Ruiz Lera
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Manuel Cobo Belaustegui
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Miguel Fernando Llano Cardenal
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Francisco González-Vílchez
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
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11
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Cabrera-Rubio I, Canteli Álvarez Á, Castrillo Bustamante C, Burgos Palacios V, Ruiz Lera M, Cobo Belaustegui M, Llano Cardenal MF, González-Vílchez F. Sensibilización durante la asistencia circulatoria de corta duración. Determinantes, tratamiento y pronóstico después del trasplante cardiaco. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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12
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Jain R, Habal MV, Clerkin KJ, Latif F, Restaino SW, Zorn E, Takeda K, Naka Y, Yuzefpolskaya M, Farr MA, Colombo PC, Sayer GT, Uriel N, Topkara VK. De Novo Human Leukocyte Antigen Allosensitization in Heartmate 3 Versus Heartmate II Left Ventricular Assist Device Recipients. ASAIO J 2022; 68:226-232. [PMID: 33883507 DOI: 10.1097/mat.0000000000001451] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Left ventricular assist devices (LVADs) are associated with the development of antihuman leukocyte antigen (HLA) antibodies, which can create a challenge for future transplantation in these patients. The differential effects of Heartmate 3 (HM3) versus Heartmate II (HMII) on de novo HLA allosensitization remain unknown. Patients who underwent HMII or HM3 implantation and had no prior HLA antibodies by solid-phase assay (Luminex) testing were included in this study. Complement-dependent cytotoxicity (CDC) panel reactive antibody (PRA) levels and Luminex antibody profiles were followed until cardiac transplantation, device explantation, or death. Electronic medical records were reviewed to examine posttransplant outcomes. Thirty-eight HM3 and 34 HMII patients with complete data were followed for 1.5 ± 1.1 years on device support. HM3 and HMII groups had similar age at implant, female gender, ischemic heart failure etiology, bridge strategy at implant, as well as intraoperative and postoperative transfusion requirements. 39.5% of HM3 and 47.1% of HMII patients developed detectable HLA antibodies by Luminex testing (p = 0.516). Development of high-level (mean fluorescence intensity >10,000) antibodies was significantly lower in HM3 than HMII patients (5.3 vs. 20.6%, p = 0.049). CDC PRA testing showed fewer HM3 patients with a positive result (PRA > 0%) than HMII patients (39.4 vs. 70.0%, p = 0.015). Among transplanted patients, those who had developed de novo sensitization on LVAD support showed a trend toward incidence of moderate to severe grade rejection compared with unsensitized patients (23.8 vs. 4.8%, p = 0.078). HM3 is associated with lower risk of de novo HLA sensitization compared with HMII.
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Affiliation(s)
- Rashmi Jain
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Marlena V Habal
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Kevin J Clerkin
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Farhana Latif
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Susan W Restaino
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Emmanuel Zorn
- Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Maryjane A Farr
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Paolo C Colombo
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Gabriel T Sayer
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Veli K Topkara
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
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13
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Chou NK, Chou HW, Tsao CI, Wang CH, Chen KPH, Chi NH, Huang SC, Yu HY, Chen YS. Impact of the Pre-Transplant Circulatory Supportive Strategy on Post-Transplant Outcome: Double Bridge May Work. J Clin Med 2021; 10:jcm10204697. [PMID: 34682819 PMCID: PMC8539306 DOI: 10.3390/jcm10204697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 10/08/2021] [Accepted: 10/09/2021] [Indexed: 11/16/2022] Open
Abstract
Background: The number of waitlisted patients requiring mechanical circulatory support (MCS) as a bridge to heart transplantation is increasing. The data concerning the results of the double-bridge strategy are limited. We sought to investigate the post-transplant outcomes across the different bridge strategies. Methods: We retrospectively reviewed a heart transplantation database from Jan 2009 to Jan 2019. Intra-aortic balloon pump (IABP), extracorporeal membrane oxygenation (ECMO), and ventricular assist devices (VAD) were the MCS that we investigated. The pre- and post-transplant characteristics and variables of patients bridged with the different types of MCS were collected. The post-transplant survival was compared using Kaplan–Meier survival analysis. Results: A total of 251 heart transplants were reviewed; 115 without MCS and 136 with MCS. The patients were divided to five groups: Group 1 (no MCS): n = 115; Group 2 (IABP): n = 15; Group 3 (ECMO): n = 33; Group 4 (ECMO-VAD): double-bridge (n = 59); Group 5 (VAD): n = 29. Survival analysis demonstrated that the 3-year post-transplant survival rates were significantly different among the groups (Log-rank p < 0.001). There was no difference in survival between group 4(ECMO-VAD) and group 1(no MCS)1 (p = 0.136), or between group 4(ECMO-VAD) and group 5(VAD) (p = 0.994). Group 3(ECMO) had significantly inferior 3-year survival than group 4(ECMO-VAD) and group 5(VAD). Conclusion: Double bridge may not lead to worse mid-term results in patients who could receive a transplantation. Initial stabilization with ECMO for critical patients before implantation of VAD might be considered as a strategy for obtaining an optimal post-transplant outcome.
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Affiliation(s)
- Nai-Kuan Chou
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, and College of Medicine, National Taiwan University, Taipei 100, Taiwan; (N.-K.C.); (H.-W.C.); (C.-H.W.); (N.-H.C.); (S.-C.H.); (H.-Y.Y.)
| | - Heng-Wen Chou
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, and College of Medicine, National Taiwan University, Taipei 100, Taiwan; (N.-K.C.); (H.-W.C.); (C.-H.W.); (N.-H.C.); (S.-C.H.); (H.-Y.Y.)
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Chuan-I Tsao
- Department of Nursing, National Taiwan University Hospital, Taipei 100, Taiwan;
| | - Chih-Hsien Wang
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, and College of Medicine, National Taiwan University, Taipei 100, Taiwan; (N.-K.C.); (H.-W.C.); (C.-H.W.); (N.-H.C.); (S.-C.H.); (H.-Y.Y.)
| | | | - Nai-Hsin Chi
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, and College of Medicine, National Taiwan University, Taipei 100, Taiwan; (N.-K.C.); (H.-W.C.); (C.-H.W.); (N.-H.C.); (S.-C.H.); (H.-Y.Y.)
| | - Shu-Chien Huang
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, and College of Medicine, National Taiwan University, Taipei 100, Taiwan; (N.-K.C.); (H.-W.C.); (C.-H.W.); (N.-H.C.); (S.-C.H.); (H.-Y.Y.)
- College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Hsi-Yu Yu
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, and College of Medicine, National Taiwan University, Taipei 100, Taiwan; (N.-K.C.); (H.-W.C.); (C.-H.W.); (N.-H.C.); (S.-C.H.); (H.-Y.Y.)
| | - Yih-Sharng Chen
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, and College of Medicine, National Taiwan University, Taipei 100, Taiwan; (N.-K.C.); (H.-W.C.); (C.-H.W.); (N.-H.C.); (S.-C.H.); (H.-Y.Y.)
- College of Medicine, National Taiwan University, Taipei 100, Taiwan
- Cardiovascular Center, National Taiwan University Hospital, Taipei 100, Taiwan
- Correspondence: ; Tel.: +886-231-23456 (ext. 65082); Fax: +886-2322-5697
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14
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Chaidaroglou A, Armenis I, Gkouziouta A, Bonios MJ, Kogerakis N, Fragoulis S, Leontiadis E, Zarkalis D, Stavridis G, Kaklamanis L, Adamopoulos S, Degiannis D. The effect of paracorporeal pulsatile biventricular assist devices on allosensitization in adults: A comparison with left ventricular assist devices. Transpl Immunol 2021; 69:101477. [PMID: 34600071 DOI: 10.1016/j.trim.2021.101477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/27/2021] [Accepted: 09/27/2021] [Indexed: 11/19/2022]
Abstract
Ventricular assist devices (VADs) have been associated with the development of anti-HLA antibodies ('allosensitization'), but data on devices providing biventricular support in adults are limited. We sought to characterize differences in anti-HLA antibody formation in adult patients receiving left- (LVAD) versus biventricular- (BiVAD) assist devices as bridge to transplantation (BTT) by retrospectively reviewing the records of adult patients who have undergone VAD implantation at our institution. We assessed 82 patients supported with a pulsatile-flow paracorporeal BiVAD and compared them with 40 patients receiving LVAD till 2018. Forty-eight (58.5%) of the BiVAD and 23 (57.5%) of the LVAD patients were eventually transplanted (p = 0.91) with an average time to transplantation 559 and 598 days, respectively (p = 0.73). Evidence of sensitization pre-VAD was found in 11.0% of the BiVAD patients and 15.0% of the LVAD ones (p = 0.53); these percentages rose to 43.9% (p < 0.001) and 40.0% (p = 0.01), respectively. The post-VAD sensitization status was not significantly different between the BiVAD and the LVAD group (p = 0.68). De novo sensitization was comparable between the two groups (p = 0.55). Post-transplantation outcomes regarding rejections and cardiac allograft vasculopathy were also similar. Conclusively, BiVAD- and LVAD- induced allosensitization do not appear to differ significantly.
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Affiliation(s)
- Antigoni Chaidaroglou
- Department of Molecular Immunopathology and Histocompatibility, Onassis Cardiac Surgery Center, Greece
| | - Iakovos Armenis
- Department of Heart Transplantation and Mechanical Circulatory Support, Onassis Cardiac Surgery Center, Greece.
| | - Angeliki Gkouziouta
- Department of Heart Transplantation and Mechanical Circulatory Support, Onassis Cardiac Surgery Center, Greece
| | - Michael J Bonios
- Department of Heart Transplantation and Mechanical Circulatory Support, Onassis Cardiac Surgery Center, Greece
| | - Nektarios Kogerakis
- Department of Heart Transplantation and Mechanical Circulatory Support, Onassis Cardiac Surgery Center, Greece
| | - Socrates Fragoulis
- Department of Heart Transplantation and Mechanical Circulatory Support, Onassis Cardiac Surgery Center, Greece
| | - Evangelos Leontiadis
- Department of Heart Transplantation and Mechanical Circulatory Support, Onassis Cardiac Surgery Center, Greece
| | - Dimitrios Zarkalis
- Department of Heart Transplantation and Mechanical Circulatory Support, Onassis Cardiac Surgery Center, Greece
| | - Georgios Stavridis
- Department of Heart Transplantation and Mechanical Circulatory Support, Onassis Cardiac Surgery Center, Greece
| | | | - Stamatis Adamopoulos
- Department of Heart Transplantation and Mechanical Circulatory Support, Onassis Cardiac Surgery Center, Greece
| | - Dimitrios Degiannis
- Department of Molecular Immunopathology and Histocompatibility, Onassis Cardiac Surgery Center, Greece
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15
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Wang M, Patel NJ, Zhang X, Kransdorf EP, Azarbal B, Kittleson MM, Czer LSC, Kobashigawa JA, Patel JK. The effects of donor-specific antibody characteristics on cardiac allograft vasculopathy. Clin Transplant 2021; 35:e14483. [PMID: 34546613 DOI: 10.1111/ctr.14483] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/30/2021] [Accepted: 09/08/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) causes late graft dysfunction and post-transplant mortality. Currently, the effects of different donor-specific antibodies (DSA) on the severity of CAV remain unclear. METHOD We evaluated 526 adult heart transplant recipients at a single center between January 2010 and August 2015. Subjects were divided into those with DSA (n = 142) and those without DSA (n = 384, control). The DSA group was stratified into persistent DSA (n = 34), transient DSA (n = 105), 1:8 dilution DSA (n = 45), complement-binding (C1q) DSA (n = 36), Class I DSA (n = 37), and Class II DSA (n = 105). The primary outcome was the incidence of moderate-to-severe CAV (CAV 2/3) at 5-year follow-up. RESULTS Subjects with persistent DSA, 1:8 dilution DSA, and C1q DSA had higher incidence of CAV 2/3 compared the control group (17.6%, 13.3%, and 16.7% vs. 3.1%, respectively; P≤ .001). The incidence of CAV 2/3 between subjects with transient DSA and the control group was similar (2.8% vs. 3.1%; P = .888). Subjects with Class II DSA also had higher incidence of CAV 2/3 (7.6% vs. 3.1%; P = .039). CONCLUSION DSA that are persistent, 1:8 dilution positive, C1q positive, and Class II are associated with more severe grades of CAV. These DSA characteristics may prognosticate disease and warrant consideration for treatment.
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Affiliation(s)
- Maggie Wang
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nikhil J Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Xiaohai Zhang
- HLA and Immunogenetics Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Babak Azarbal
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michelle M Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Lawrence S C Czer
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jignesh K Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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16
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Habal MV. Current Desensitization Strategies in Heart Transplantation. Front Immunol 2021; 12:702186. [PMID: 34504489 PMCID: PMC8423343 DOI: 10.3389/fimmu.2021.702186] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/26/2021] [Indexed: 01/03/2023] Open
Abstract
Heart transplant candidates sensitized to HLA antigens wait longer for transplant, are at increased risk of dying while waiting, and may not be listed at all. The increasing prevalence of HLA sensitization and limitations of current desensitization strategies underscore the urgent need for a more effective approach. In addition to pregnancy, prior transplant, and transfusions, patients with end-stage heart failure are burdened with unique factors placing them at risk for HLA sensitization. These include homograft material used for congenital heart disease repair and left ventricular assist devices (LVADs). Moreover, these risks are often stacked, forming a seemingly insurmountable barrier in some cases. While desensitization protocols are typically implemented uniformly, irrespective of the mode of sensitization, the heterogeneity in success and post-transplant outcomes argues for a more tailored approach. Achieving this will require progress in our understanding of the immunobiology underlying the innate and adaptive immune response to these varied allosensitizing exposures. Further attention to B cell activation, memory, and plasma cell differentiation is required to establish methods that durably abrogate the anti-HLA antibody response before and after transplant. The contribution of non-HLA antibodies to the net state of sensitization and the potential implications for graft longevity also remain to be comprehensively defined. The aim of this review is to first bring forth select issues unique to the sensitized heart transplant candidate. The current literature on desensitization in heart transplantation will then be summarized providing context within the immune response. Building on this, newer approaches with therapeutic potential will be discussed emphasizing the importance of not only addressing the short-term pathogenic consequences of circulating HLA antibodies, but also the need to modulate alloimmune memory.
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Affiliation(s)
- Marlena V. Habal
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, Columbia University, New York, NY, United States
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17
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Itoda Y, Okamoto T, Niikawa H, Ayyat KS, Tu C, McCurry KR. Ventricular assist device bridging with gender-mismatch increases rejection and decreases survival following a heart transplant. Eur J Cardiothorac Surg 2021; 59:217-225. [PMID: 33057607 DOI: 10.1093/ejcts/ezaa270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 06/02/2020] [Accepted: 06/11/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Survival is poor following an orthotopic heart transplant with gender-mismatched donors and recipients. Patients bridged to an orthotopic heart transplant with a ventricular assist device (VAD) frequently become sensitized. We hypothesized that the combination of VAD bridging and gender-mismatch may result in greater rejection and poorer survival. METHODS Data were obtained from the United Network of Organ Sharing database. Patients were divided into 4 groups: (i) VAD recipients who received a heart from a gender-matched donor (VAD-M); (ii) VAD recipients who received a heart from a gender-mismatched donor (VAD-MM); (iii) noVAD recipients who received a heart from a gender-matched donor (noVAD-M); and (iv) noVAD recipients who received a heart from a gender-mismatched donor (noVAD-MM). Rejection episodes within 1-year post-transplant and transplant survival were compared in VAD-M versus VAD-MM and noVAD-M versus noVAD-MM groups, respectively. RESULTS Between January 2000 and June 2017, of 33 401 adult patients who underwent heart transplants, 8648, 2441, 12 761 and 4992 patients were identified as VAD-M, VAD-MM, noVAD-M and noVAD-MM, respectively. Rejection within 1-year post-transplant occurred in 23.3% and 27.3% of the VAD-M and VAD-MM groups, respectively (P < 0.01) and in 21.8% and 23.6% of the noVAD-M and noVAD-MM groups (P = 0.02), respectively. In an adjusted survival analysis, the VAD-MM group showed significantly worse survival than the VAD-M group (P < 0.01), whereas there was no significant difference between the noVAD-M and noVAD-MM groups (P = 0.21). CONCLUSIONS Our results indicated that the combination of VAD bridging and gender-mismatch caused greater rejection and worse survival following a transplant. Further study is necessary to prove comparable post-transplant survival of gender-matched or -mismatched recipients without VAD bridging.
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Affiliation(s)
- Yoshifumi Itoda
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Toshihiro Okamoto
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA.,Transplant Center, Cleveland Clinic, Cleveland, OH, USA
| | - Hiromichi Niikawa
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Kamal S Ayyat
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA.,Department of Cardiothoracic Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Chao Tu
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Kenneth R McCurry
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA.,Transplant Center, Cleveland Clinic, Cleveland, OH, USA
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18
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Holzhauser L, Clerkin KJ, Fujino T, Alenghat FJ, Raikhelkar J, Kim G, Sayer G, Uriel N. Donor-derived cell-free DNA is associated with cardiac allograft vasculopathy. Clin Transplant 2021; 35:e14206. [PMID: 33368611 PMCID: PMC10040222 DOI: 10.1111/ctr.14206] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/20/2020] [Accepted: 12/07/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The role of donor-derived cell-free DNA (dd-cfDNA) in screening for cardiac allograft vasculopathy (CAV) is unknown. We hypothesized that dd-cfDNA correlates with CAV, markers of inflammation, and angiogenesis in stable heart transplant (HT) recipients. METHODS Sixty-five HT recipients ≥2 years post-transplant, without recent rejection, were stratified by high (≥0.12%) versus low levels (<0.12%) of dd-cfDNA. A targeted amplification, next-generation sequencing assay (AlloSure® ; CareDx, Inc.) was used to detect dd-cfDNA. Peripheral blood inflammatory and angiogenesis markers were assessed using a multiplex immunoassay system (Bioplex® ). RESULTS Of 65 patients, 58 patients had a known CAV status and were included. Thirty had high levels of dd-cfDNA (≥0.12%), and 28 had low levels (<0.12%). CAV was present in 63% of patients with high dd-cfDNA vs. 35% with low dd-cfDNA (p = .047). Donor-specific antibodies were present in 25% of patients with high dd-cfDNA vs. 3.8% in those with low dd-cfDNA (p = .03). There were no differences in rejection episodes, inflammatory, or angiogenesis markers. Importantly, dd-cfDNA levels were not different when stratified by time post-transplant. CONCLUSIONS Higher dd-cfDNA levels were associated with CAV in stable chronic HT recipients. Further studies are warranted to investigate a possible association between dd-cfDNA levels and CAV severity and whether dd-cfDNA can predict CAV progression.
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Affiliation(s)
- Luise Holzhauser
- Department of Cardiology, University of Chicago, Chicago, IL, USA
| | - Kevin J Clerkin
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Takeo Fujino
- Department of Cardiology, University of Chicago, Chicago, IL, USA
| | | | - Jayant Raikhelkar
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Gene Kim
- Department of Cardiology, University of Chicago, Chicago, IL, USA
| | - Gabriel Sayer
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Nir Uriel
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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19
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Huckaby LV, Seese LM, Hickey G, Sultan I, Kilic A. A mortality risk score for heart transplants after contemporary ventricular assist device bridging. J Card Surg 2020; 36:449-456. [PMID: 33284503 DOI: 10.1111/jocs.15188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/03/2020] [Accepted: 10/22/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND We sought to derive a risk score for 1-year mortality following orthotopic heart transplantation (OHT) in patients bridged with a contemporary centrifugal left ventricular assist device (LVAD). METHODS Adult patients (≥18 years) in the United Network for Organ Sharing database undergoing OHT between 2010 and 2019 who were bridged with a HeartWare or HeartMate III device were included. Derivation and validation cohorts were randomly assigned with a 2:1 ratio. Threshold analysis and multivariable logistic regression were utilized to obtain adjusted odds ratios for 1-year post-OHT mortality. A risk score was generated using these adjusted odds ratios in the derivation cohort and the predictive performance of the composite index was evaluated in the validation set. RESULTS A total of 3434 patients were identified. In the derivation cohort, the mean age was 53.5 ± 12.1 years and 1758 (76.8%) were male; 1789 (78.1%) were bridged with a HeartWare device. Multivariable logistic regression revealed that recipient age ≥50 years, bilirubin level ≥2.4 mg/dl, ischemic time ≥4 h, and preoperative hemodialysis predicted 1-year post-transplant mortality. Stratification into risk groups in the validation cohort revealed significant differences in postoperative renal failure, stroke, and short-term mortality. One-year post-transplant mortality was 5%, 6.7%, and 14.8% in the low-, moderate-, and high-risk categories, respectively (p < .001). CONCLUSIONS Among patients bridged to OHT with newer generation centrifugal LVADs, older age, increasing bilirubin, longer ischemic time, and pre-OHT dialysis independently predicted post-transplant mortality. The composite risk score based on these factors may assist in patient selection and prognostication in those supported with contemporary LVADs.
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Affiliation(s)
- Lauren V Huckaby
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Laura M Seese
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Gavin Hickey
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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20
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Pierson RN, Burdorf L, Madsen JC, Lewis GD, D’Alessandro DA. Pig-to-human heart transplantation: Who goes first? Am J Transplant 2020; 20:2669-2674. [PMID: 32301262 PMCID: PMC9448330 DOI: 10.1111/ajt.15916] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/05/2020] [Accepted: 04/06/2020] [Indexed: 01/25/2023]
Abstract
Cardiac xenotransplantation has recently taken an important step towards clinical reality. In anticipation of the "first-in-human" heart xenotransplantation trial, we propose a set of patient characteristics that define potential candidates. Our premise is that, to be ethically justified, the risks posed by current state-of-the-art options must outweigh the anticipated risks of a pioneering xenotransplant procedure. Suitable candidates include patients who are at high immunologic risk because of sensitization to alloantigens, including those who have exhibited early onset or accelerated cardiac allograft vasculopathy. In addition, patients should be considered (1) for whom mechanical circulatory support would be prohibitively risky due to a hypercoagulable state, a contraindication to anticoagulation, or restrictive physiology; (2) with severe biventricular dysfunction predicting unsuccessful univentricular left heart support; and (3) adults with complex congenital heart disease. In conclusion, because the published preclinical benchmark for clinical translation of heart xenotransplantation appears within reach, carefully and deliberately defining appropriate trial participants is timely as the basis for ethical clinical trial design.
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Affiliation(s)
- Richard N. Pierson
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts,Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts
| | - Lars Burdorf
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts,Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts
| | - Joren C. Madsen
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts,Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts
| | - Gregory D. Lewis
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts
| | - David A. D’Alessandro
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts
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21
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Bakir NH, Finnan MJ, MacGregor RM, Schilling JD, Ewald GA, Kotkar KD, Itoh A, Damiano RJ, Moon MR, Masood MF. Cardiac allograft rejection in the current era of continuous flow left ventricular assist devices. J Thorac Cardiovasc Surg 2020; 163:124-134.e8. [PMID: 33012541 DOI: 10.1016/j.jtcvs.2020.06.142] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 05/28/2020] [Accepted: 06/08/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Left ventricular assist device (LVAD) implantation has been shown to increase allosensitization before orthotopic heart transplantation, but the influence of LVAD support on posttransplant rejection is controversial. This study examines the postoperative incidence of acute cellular rejection (ACR) in patients bridged with continuous flow LVAD (CF-LVAD) relative to primary transplant (Primary Tx). METHODS All patients who underwent orthotopic heart transplantation at our institution between July 2006 and March 2019 were retrospectively reviewed (n = 395). Patients were classified into Primary Tx (n = 145) and CF-LVAD (n = 207) groups. Propensity score matching on 13 covariates implemented a 0.1 caliper logistic model with nearest neighbor 1:1 matching. Development of moderate to severe (ie, 2R/3R) rejection was evaluated using a competing risks model. Potential predictors of 2R/3R ACR were evaluated using Fine-Gray regression on the marginal subdistribution hazard. RESULTS Propensity score matching yielded 122 patients in each group (n = 244). At 12 and 24 months, the cumulative incidence of 2R/3R ACR was 17% and 23% for the CF-LVAD group and 26% and 31%, respectively, for the Primary Tx group (P = .170). CF-LVAD was not predictive of 2R/3R rejection on multivariable Fine-Gray regression (subdistribution hazard ratio, 0.73; 95% confidence interval, 0.40-1.33; P = .301). There was no difference in the 5-year incidence of antibody mediated rejection (10% [n = 12] vs 9% [n = 11]; P = .827). CONCLUSIONS After adjusting for covariates, CF-LVAD was not associated with an increased risk of moderate to severe ACR during the 24 months after cardiac transplantation. Further investigation is warranted with larger cohorts, but CF-LVAD may have minimal influence on posttransplant ACR.
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Affiliation(s)
- Nadia H Bakir
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo
| | - Michael J Finnan
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo
| | - Robert M MacGregor
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo
| | - Joel D Schilling
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo; Department of Pathology and Immunology, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo
| | - Gregory A Ewald
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo
| | - Kunal D Kotkar
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo
| | - Akinobu Itoh
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo
| | - Muhammad F Masood
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo.
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22
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Bedanova H, Pazdernik M, Sonka M, Zhi C, Krejci J, Novakova M, Dobsak P, Nemec P. Effects of implanting a long-term left ventricle assist device on post-transplant outcomes. Int J Artif Organs 2020; 44:39-45. [PMID: 32329386 DOI: 10.1177/0391398820914626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND An increasing number of patients are receiving left ventricle assist devices as a bridge to heart transplantation. The aim of this study was to determine the difference between patients who received transplants from a left ventricle assist device and those who underwent heart transplantation without a prior left ventricle assist device implantation. MATERIAL AND METHODS The study included patients who underwent heart transplantation in our institute between January 2010 and November 2018. The following clinical variables were evaluated: donor characteristics, patient's pre-transplant demographical data, post-transplant data, and patient survival. Cardiac allograft vasculopathy progression was prospectively examined (after 1 month and 12 months after heart transplantation) by coronary optical coherence tomography. We were interested in the difference in 1- and 5-year survival between the left ventricle assist device and non-left ventricle assist device groups. RESULTS A total of 248 patients were identified; out of them, 48 patients received a left ventricle assist device before heart transplantation, whereas 200 had transplants with no prior left ventricle assist device implantation. There were no significant differences in any donor characteristics. The mean duration of cardiopulmonary bypass time in the non-left ventricle assist device group was 156 versus 175 min in the left ventricle assist device group (p = 0.009), blood loss was 650 versus 1045 mL (p < 0.001), the need to implant an extracorporeal membrane oxygenation was 10% versus 23% (p = 0.02). There was no difference in cardiac allograft vasculopathy progression between the groups 1 year after heart transplantation (p = 0.528). The 1- and 5-year survival, according to Kaplan-Meier, was 80% and 70% in the left ventricle assist device group, compared to 80% and 73%, respectively, in the non-left ventricle assist device group (Log-rank test: p = 0.945). CONCLUSION Our results indicate that patients undergoing heart transplantation from left ventricle assist devices suffer significantly more from intraoperative and post-operative complications; however, only insignificant cardiac allograft vasculopathy progression and survival differences between the two groups were observed.
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Affiliation(s)
- Helena Bedanova
- Center of Cardiovascular and Transplant Surgery Brno, Brno, Czech Republic
| | - Michal Pazdernik
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | | | - Chen Zhi
- The University of Iowa, Iowa City, IA, USA
| | - Jan Krejci
- Department of Sports Medicine and Rehabilitation, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Marie Novakova
- Department of Sports Medicine and Rehabilitation, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Petr Dobsak
- Department of Sports Medicine and Rehabilitation, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Petr Nemec
- Center of Cardiovascular and Transplant Surgery Brno, Brno, Czech Republic
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23
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Transplant Outcomes in Destination Therapy Left Ventricular Assist Device Patients. ASAIO J 2020; 66:394-398. [DOI: 10.1097/mat.0000000000001016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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24
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Desensitization in the Era of Precision Medicine: Moving From the Bench to Bedside. Transplantation 2019; 103:1574-1581. [DOI: 10.1097/tp.0000000000002737] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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25
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Yin MY, Wever-Pinzon O, Mehra MR, Selzman CH, Toll AE, Cherikh WS, Nativi-Nicolau J, Fang JC, Kfoury AG, Gilbert EM, Kemeyou L, McKellar SH, Koliopoulou A, Vaduganathan M, Drakos SG, Stehlik J. Post-transplant outcome in patients bridged to transplant with temporary mechanical circulatory support devices. J Heart Lung Transplant 2019; 38:858-869. [DOI: 10.1016/j.healun.2019.04.003] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 03/20/2019] [Accepted: 04/14/2019] [Indexed: 01/06/2023] Open
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26
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Colvin MM, Cook JL, Chang PP, Hsu DT, Kiernan MS, Kobashigawa JA, Lindenfeld J, Masri SC, Miller DV, Rodriguez ER, Tyan DB, Zeevi A. Sensitization in Heart Transplantation: Emerging Knowledge: A Scientific Statement From the American Heart Association. Circulation 2019; 139:e553-e578. [DOI: 10.1161/cir.0000000000000598] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Sensitization, defined as the presence of circulating antibodies, presents challenges for heart transplant recipients and physicians. When present, sensitization can limit a transplantation candidate’s access to organs, prolong wait time, and, in some cases, exclude the candidate from heart transplantation altogether. The management of sensitization is not yet standardized, and current therapies have not yielded consistent results. Although current strategies involve antibody suppression and removal with intravenous immunoglobulin, plasmapheresis, and antibody therapy, newer strategies with more specific targets are being investigated.
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27
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Chan JL, Miller JG, Singh AK, Horvath KA, Corcoran PC, Mohiuddin MM. Consideration of appropriate clinical applications for cardiac xenotransplantation. Clin Transplant 2018; 32:e13330. [DOI: 10.1111/ctr.13330] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Joshua L. Chan
- Cardiothoracic Surgery Research Program/National Heart; Lung and Blood Institute; National Institutes of Health; Bethesda MD USA
| | - Justin G. Miller
- Cardiothoracic Surgery Research Program/National Heart; Lung and Blood Institute; National Institutes of Health; Bethesda MD USA
| | - Avneesh K. Singh
- Cardiothoracic Surgery Research Program/National Heart; Lung and Blood Institute; National Institutes of Health; Bethesda MD USA
| | - Keith A. Horvath
- Cardiothoracic Surgery Research Program/National Heart; Lung and Blood Institute; National Institutes of Health; Bethesda MD USA
| | - Philip C. Corcoran
- Cardiothoracic Surgery Research Program/National Heart; Lung and Blood Institute; National Institutes of Health; Bethesda MD USA
| | - Muhammad M. Mohiuddin
- Cardiothoracic Surgery Research Program/National Heart; Lung and Blood Institute; National Institutes of Health; Bethesda MD USA
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28
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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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29
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Cooper DK, Wijkstrom M, Hariharan S, Chan JL, Singh A, Horvath K, Mohiuddin M, Cimeno A, Barth RN, LaMattina JC, Pierson RN. Selection of Patients for Initial Clinical Trials of Solid Organ Xenotransplantation. Transplantation 2017; 101:1551-1558. [PMID: 27906824 PMCID: PMC5453852 DOI: 10.1097/tp.0000000000001582] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Several groups have reported extended survival of genetically engineered pig organs in nonhuman primates, varying from almost 10 months for life-supporting kidney grafts and more than 2 years for non-life-supporting heart grafts to less than 1 month for life-supporting liver and lung grafts. We have attempted to define groups of patients who may not have an option to wait for an allograft. These include kidney, heart, and lung candidates who are highly-allosensitized. In addition, some kidney candidates (who have previously lost at least 2 allografts from rapid recurrence of native kidney disease) have a high risk of further recurrence and will not be offered a repeat allotransplant. Patients with complex congenital heart disease, who may have undergone previous palliative surgical procedures, may be unsuitable for ventricular assist device implantation. Patients dying of fulminant hepatic failure, for whom no alternative therapy is available, may be candidates for a pig liver, even if only as a bridge until an allograft becomes available. When the results of pig organ xenotransplantation in nonhuman primates suggest a realistic potential for success of a pilot clinical trial, highly selected patients should be offered participation.
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Affiliation(s)
- David K.C. Cooper
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Martin Wijkstrom
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Sundaram Hariharan
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Joshua L. Chan
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Avneesh Singh
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Keith Horvath
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Muhammad Mohiuddin
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Arielle Cimeno
- Division of Transplantation Surgery, Department of Surgery, University of Maryland, Baltimore VAMC, Baltimore, MD
| | - Rolf N. Barth
- Division of Transplantation Surgery, Department of Surgery, University of Maryland, Baltimore VAMC, Baltimore, MD
| | - John C. LaMattina
- Division of Transplantation Surgery, Department of Surgery, University of Maryland, Baltimore VAMC, Baltimore, MD
| | - Richard N. Pierson
- Division of Cardiac Surgery, Department of Surgery, University of Maryland, Baltimore VAMC, Baltimore, MD, USA
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30
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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
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31
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Antibody-mediated rejection in the cardiac allograft: diagnosis, treatment and future considerations. Curr Opin Cardiol 2017; 32:326-335. [PMID: 28212151 DOI: 10.1097/hco.0000000000000390] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW This review summarizes the latest publications dealing with antibody-mediated rejection (AMR) and defines areas of controversy and future steps that may improve the outcome for patients with this virulent form of rejection. RECENT FINDINGS Recent progress includes publication of standardized pathologic criteria for acute AMR by the International Society for Heart and Lung Transplantation (ISHLT) and guidelines for treatment of acute AMR by the American Heart Association, endorsed by ISHLT as well. Recently published review articles emphasize the important role of innate immune mechanisms, clarify the role of viral infection and provide insights into vascular biology and the role of innate effector populations, macrophages and dendritic cells. SUMMARY Strategies for future studies are discussed in the context of these new findings and similar efforts undertaken by renal and liver allograft investigators.
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32
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See SB, Clerkin KJ, Kennel PJ, Zhang F, Weber MP, Rogers KJ, Chatterjee D, Vasilescu ER, Vlad G, Naka Y, Restaino SW, Farr MA, Topkara VK, Colombo PC, Mancini DM, Schulze PC, Levin B, Zorn E. Ventricular assist device elicits serum natural IgG that correlates with the development of primary graft dysfunction following heart transplantation. J Heart Lung Transplant 2017; 36:862-870. [PMID: 28431981 DOI: 10.1016/j.healun.2017.03.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/28/2017] [Accepted: 03/22/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Pre-transplant sensitization is a limiting factor in solid-organ transplantation. In heart transplants, ventricular assist device (VAD) implantation has been associated with sensitization to human leukocyte antigens (HLA). The effect of VAD on non-HLA antibodies is unclear. We have previously shown that polyreactive natural antibodies (Nabs) contribute to pre-sensitization in kidney allograft recipients. Here we assessed generation of Nabs after VAD implantation in pre-transplant sera and examined their contribution to cardiac allograft outcome. METHODS IgM and IgG Nabs were tested in pre-transplant serum samples collected from 206 orthotopic heart transplant recipients, including 128 patients with VAD (VAD patients) and 78 patients without VAD (no-VAD patients). Nabs were assessed by testing serum reactivity to apoptotic cells by flow cytometry and to the generic oxidized epitope, malondialdehyde, by enzyme-linked immunosorbent assay. RESULTS No difference was observed in serum levels of IgM Nabs between VAD and no-VAD patients. However, serum IgG Nabs levels were significantly increased in VAD compared with no-VAD patients. This increase was likely due to the presence of the VAD, as revealed by lower serum IgG Nabs levels before implantation. Elevated pre-transplant IgG Nabs level was associated with development of primary graft dysfunction (PGD). CONCLUSIONS Our study demonstrates that VAD support elicits IgG Nabs reactive to apoptotic cells and oxidized epitopes. These findings further support broad and non-specific B-cell activation by VAD, resulting in IgG sensitization. Moreover, the association of serum IgG Nabs levels with development of PGD suggests a possible role for these antibodies in the inflammatory reaction accompanying this complication.
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Affiliation(s)
- Sarah B See
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York
| | - Kevin J Clerkin
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Peter J Kennel
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York
| | - Feifan Zhang
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Matthew P Weber
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Kortney J Rogers
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York
| | - Debanjana Chatterjee
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York
| | - Elena R Vasilescu
- Department of Pathology and Cell Biology, Department of Surgery, Columbia University Medical Center, New York, New York
| | - George Vlad
- Department of Pathology and Cell Biology, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Susan W Restaino
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Maryjane A Farr
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Donna M Mancini
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - P Christian Schulze
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Bruce Levin
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Emmanuel Zorn
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York.
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