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Franco Acevedo A, Mack JJ, Valenzuela NM. The transcriptional repressor B cell lymphoma 6 regulates CXCR3 chemokine and human leukocyte antigen II expression in endothelial cells. Am J Transplant 2024:S1600-6135(24)00449-0. [PMID: 39074669 DOI: 10.1016/j.ajt.2024.07.026] [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: 03/12/2024] [Revised: 07/08/2024] [Accepted: 07/23/2024] [Indexed: 07/31/2024]
Abstract
Interferon gamma (IFN-γ) induces an endothelial proimmunogenic phenotype through the JAK/STAT1 pathway, which can shape the activation of alloreactive leukocytes in transplant rejection. In immune cells, the DNA-binding protein B cell lymphoma 6 (BCL6) controls the transcription of inflammatory genes. This study tested if BCL6 modulates IFN-γ-induced gene expression in endothelial cells. In vitro, BCL6 was IFN-γ-inducible in primary human endothelium, along with CXCR3 chemokines and human leukocyte antigen (HLA). BCL6, HLA II, and CXCL9 were also increased in human cardiac transplants during acute rejection. Knockdown of BCL6 augmented, whereas overexpression and BTB domain inhibitors (BCL6-BTBi) suppressed, HLA II and CXCR3 chemokine expression but not HLA I. Further, BCL6 had a greater effect on HLA-DR and DP but was less involved in regulating HLA-DQ expression. The effect correlated with BCL6 binding motifs in or near affected genes. The BCL6 DNA recognition sequence was highly similar to that of STAT1, and BTBi reduced STAT1's transcriptional activity in vitro. Our results show for the first time that BCL6 selectively controls IFN-γ-induced endothelial gene expression, advancing our understanding of the endogenous mechanisms regulating donor immunogenicity.
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Affiliation(s)
- Adriana Franco Acevedo
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, USA
| | - Julia J Mack
- Department of Cardiology, University of California, Los Angeles, USA
| | - Nicole M Valenzuela
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, USA.
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2
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Otunla AA, Shanmugarajah K, Davies AH, Lucia Madariaga M, Shalhoub J. The Biological Parallels Between Atherosclerosis and Cardiac Allograft Vasculopathy: Implications for Solid Organ Chronic Rejection. Cardiol Rev 2024; 32:2-11. [PMID: 38051983 DOI: 10.1097/crd.0000000000000437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Atherosclerosis and solid organ chronic rejection are pervasive chronic disease states that account for significant morbidity and mortality in developed countries. Recently, a series of shared molecular pathways have emerged, revealing biological parallels from early stages of development up to the advanced forms of pathology. These shared mechanistic processes are inflammatory in nature, reflecting the importance of inflammation in both disorders. Vascular inflammation triggers endothelial dysfunction and disease initiation through aberrant vasomotor control and shared patterns of endothelial activation. Endothelial dysfunction leads to the recruitment of immune cells and the perpetuation of the inflammatory response. This drives lesion formation through the release of key cytokines such as IFN-y, TNF-alpha, and IL-2. Continued interplay between the adaptive and innate immune response (represented by T lymphocytes and macrophages, respectively) promotes lesion instability and thrombotic complications; hallmarks of advanced disease in both atherosclerosis and solid organ chronic rejection. The aim of this study is to identify areas of overlap between atherosclerosis and chronic rejection. We then discuss new approaches to improve current understanding of the pathophysiology of both disorders, and eventually design novel therapeutics.
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Affiliation(s)
- Afolarin A Otunla
- From the Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | | | - Alun H Davies
- Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | - Joseph Shalhoub
- Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
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3
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Shahandeh N, Parikh RV. Invasive Intracoronary Imaging of Cardiac Allograft Vasculopathy: Established Modalities and Emerging Technologies. Interv Cardiol Clin 2023; 12:269-280. [PMID: 36922067 DOI: 10.1016/j.iccl.2022.12.005] [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: 03/18/2023]
Abstract
Despite advances in the care of heart transplant recipients during the past 5 decades, cardiac allograft vasculopathy (CAV) continues to be a major barrier to long-term survival. The early diagnosis and treatment of CAV is crucial for improving long-term outcomes. Coronary angiography, the current gold standard for CAV screening, has low sensitivity for detecting early CAV. Increasingly, invasive intracoronary imaging modalities that provide a more detailed analysis of vessel anatomy and allow for plaque characterization are being used to detect CAV earlier after transplant and uncover mechanistic insights. Studies validating these emerging imaging platforms are needed before their widespread adoption.
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Affiliation(s)
- Negeen Shahandeh
- Division of Cardiology, University of California, 100 Medical Plaza, Suite 630 East, Los Angeles, CA 90095, USA
| | - Rushi V Parikh
- Division of Cardiology, University of California, Los Angeles, 100 Medical Plaza, Suite 630 West, Los Angeles, CA 90095, USA.
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4
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Seguchi O, Azarbal B, Mirocha J, Youn JC, Passano E, Patel J, Kobashigawa J. Change in First-year Intravascular Ultrasound Results Predicts Adverse Events in Heart Transplant Recipients: Implications for Clinical Trial Endpoints. Transplantation 2023; 107:737-747. [PMID: 36358011 DOI: 10.1097/tp.0000000000004395] [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: 11/13/2022]
Abstract
BACKGROUND Heart transplantation (HTx) is an established therapeutic option for patients with advanced heart failure who are refractory to conventional guideline-directed treatments. This study aimed to reassess whether intravascular ultrasound variables could predict adverse events after HTx in the modern era. METHODS One hundred primary HTx recipients with available serial intravascular ultrasound examination results of the left anterior descending artery 4-8 wk and 1 y after HTx were enrolled, with an average follow-up duration of 5.7 y. The primary endpoint was a composite of all-cause death, nonfatal major adverse cardiac events, and angiographic cardiac allograft vasculopathy. RESULTS Forty-three patients developed primary endpoints. The baseline maximal intimal thickness was independently associated with the primary endpoint (hazard ratio, 8.24; 95% confidential interval [CI], 3.21-21.21; P < 0.001), and the optimal cutoff value was 0.64 mm. A change in the plaque atheroma volume in a proximal 20-mm segment from the left anterior descending artery bifurcation >1.05 mm 3 /mm (hazard ratio, 2.75; 95% CI, 1.28-5.89; P = 0.009) and a change in the first-year maximal intimal thickness >0.27 mm (hazard ratio, 2.63; 95% CI, 1.05-6.56; P = 0.04) were independent predictors of the primary endpoint 1 y after intravascular ultrasonography. CONCLUSIONS The aforementioned important clinical implications of intravascular ultrasound parameters are useful predictors of outcomes, which may be considered endpoints in modern clinical HTx trials.
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Affiliation(s)
- Osamu Seguchi
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Babak Azarbal
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
| | - James Mirocha
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jong-Chan Youn
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Elizabeth Passano
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
| | - Jignesh Patel
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
| | - Jon Kobashigawa
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
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Ozcan I, Toya T, Corban MT, Ahmad A, Lerman LO, Kushwaha SS, Lerman A. Peripheral microvascular dysfunction is associated with plaque progression and adverse long-term outcomes in heart transplant patients. ESC Heart Fail 2021; 8:5266-5274. [PMID: 34510802 PMCID: PMC8712915 DOI: 10.1002/ehf2.13610] [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: 04/21/2021] [Revised: 08/17/2021] [Accepted: 09/01/2021] [Indexed: 11/21/2022] Open
Abstract
Aims Cardiac allograft vasculopathy (CAV) is the major cause of increased morbidity and mortality after heart transplantation. Peripheral endothelial dysfunction (PED) is associated with early atherosclerosis and future risk of major adverse cardiovascular events (MACE) in non‐heart transplant population. We aimed to investigate the association of PED with future MACE, and plaque progression assessed by intravascular ultrasound (IVUS) after heart transplantation. Methods and results We included 66 transplant patients who underwent serial IVUS surveillance for CAV and baseline assessment of peripheral endothelial function using reactive hyperaemia peripheral arterial tonometry. PED was defined as reactive hyperaemia index < 2. The primary endpoint of the study was to investigate the association of PED with CAV progression assessed by intravascular ultrasound (IVUS). CAV progression was assessed as the change (Δ) in plaque volume divided by segment length, and Δ plaque index (plaque volume/vessel volume), adjusted for the time between IVUS measurements (median 3.0 [2.2, 3.1] years). The secondary endpoint was to investigate the association between PED and future MACE, which was defined as any incident of revascularization, heart failure hospitalization, stroke, myocardial infarction, re‐transplantation, and death. Patients with PED (n = 27) had more yearly plaque progression (0.50 ± 0.66 vs. 0.15 ± 0.50 mm3/mm/year, P = 0.02) and a higher Δ plaque index (2.41 ± 2.53% vs. 0.69 ± 2.22%, P = 0.01). Patients with PED were more likely to experience MACE during a median follow‐up of 8.2 years (interquartile range [7.6, 8.4]), after adjustment for potential cofounders such as age, high‐density lipoprotein cholesterol levels, total rejection score, baseline International Society for Heart & Lung Transplantation CAV grade, and indication of transplantation. (hazard ratio 2.15, 95% confidence interval [1.09, 4.23], P = 0.03). Conclusions Peripheral endothelial dysfunction is associated with increased plaque progression and adverse long‐term cardiovascular outcomes in transplant patients. PED assessment might be a useful clinical tool for risk stratification after heart transplantation.
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Affiliation(s)
- Ilke Ozcan
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55902, USA
| | - Takumi Toya
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55902, USA.,Division of Cardiology, National Defense Medical College, Tokorozawa, Japan
| | - Michel T Corban
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55902, USA
| | - Ali Ahmad
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55902, USA
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55902, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55902, USA
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Siao WZ, Liu CH, Wang YH, Wei JCC, Jong GP. Increased risk of valvular heart disease in patients with ankylosing spondylitis: a nationwide population-based longitudinal cohort study. Ther Adv Musculoskelet Dis 2021; 13:1759720X211021676. [PMID: 34211590 PMCID: PMC8216336 DOI: 10.1177/1759720x211021676] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/11/2021] [Indexed: 01/19/2023] Open
Abstract
Aims: We aimed to evaluate the risk of valvular heart disease (VHD) among patients with ankylosing spondylitis (AS). Methods: This was a population-based cohort study utilizing the Longitudinal Health Insurance Research Database of the National Health Insurance in Taiwan. Patients with and without coding of newly diagnosed AS from 1999 to 2013 were assigned to the AS and non-AS groups, respectively. Primary outcome was the incidental risk of VHD. Multiple Cox regression was used to estimate the adjusted hazard ratio of VHD. Subgroup analysis and sensitivity tests were also conducted. Results: The AS group included 3780 patients, and 22,680 matched subjects without an AS diagnosis were identified as controls. The AS group had an increased risk of VHD compared with non-AS controls (adjusted hazard ratio: 1.63; 95% confidence interval: 1.43–1.86; p < 0.001). Subgroup analysis also revealed an increased risk of individual types of VHD, including aortic, mitral, and tricuspid valve disease. Patients in the AS group had a higher incidence of valve replacement surgery after the onset of VHD. Conclusion: Patients with AS had a significant risk of VHD compared to non-AS controls in this population-based cohort study. Screening for VHD may be needed in caring patients with AS. We suggest that echocardiography may be performed when patients are diagnosed with AS.
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Affiliation(s)
- Wun-Zhih Siao
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital and Chung Shan Medical University, Taichung
| | - Chin-Hsiu Liu
- Division of Allergy, Immunology and Rheumatology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City
| | - Yu-Hsun Wang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung
| | - James Cheng-Chung Wei
- Department of Allergy, Immunology & Rheumatology, Chung Shan Medical University Hospital, Taichung
| | - Gwo-Ping Jong
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital and Chung Shan Medical University, No. 110, Sec. 1, Chien-Kuo N. Road, Taichung, 40201
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7
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Abstract
Heart transplantation (HTx) remains the optimal treatment for selected patients with end-stage advanced heart failure. However, survival is limited early by acute rejection and long term by cardiac allograft vasculopathy (CAV). Even though the diagnosis of rejection is based on histology, cardiac imaging provides a pivotal role for early detection and severity assessment of these hazards. The present review focuses on the use and reliability of different invasive and non-invasive imaging modalities to detect and monitor CAV and rejection after HTx. Coronary angiography remains the corner stone in routine CAV surveillance. However, angiograms are invasive and underestimates the CAV severity especially in the early phase. Intravascular ultrasound and optical coherence tomography are invasive methods for intracoronary imaging that detects early CAV lesions not evident by angiograms. Non-invasive imaging can be divided into myocardial perfusion imaging, anatomical/structural imaging and myocardial functional imaging. The different non-invasive imaging modalities all provide clinical and prognostic information and may have a gatekeeper role for invasive monitoring. Acute rejection and CAV are still significant clinical problems after HTx. No imaging modality provides complete information on graft function, coronary anatomy and myocardial perfusion. However, a combination of invasive and non-invasive modalities at different stages following HTx should be considered for optimal personalized surveillance and risk stratification.
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Affiliation(s)
| | | | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Denmark
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8
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“Cardiac allograft vasculopathy: Pathogenesis, diagnosis and therapy”. Transplant Rev (Orlando) 2020; 34:100569. [DOI: 10.1016/j.trre.2020.100569] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/19/2020] [Indexed: 01/06/2023]
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9
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Spitaleri G, Farrero Torres M, Sabatino M, Potena L. The pharmaceutical management of cardiac allograft vasculopathy after heart transplantation. Expert Opin Pharmacother 2020; 21:1367-1376. [PMID: 32401066 DOI: 10.1080/14656566.2020.1753698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Cardiac allograft vasculopathy (CAV) is a major limitation to long-term survival after heart transplantation. Its peculiar pathophysiology involves multifactorial pathways including immune-mediated and metabolic risk factors, which are associated with the development of specific pathological lesions. The often diffuse and chronic nature of the disease reduces the effectiveness of revascularization procedures, and pharmacological prevention of the disease is the sole therapeutic approach with some proven efficacy. AREAS COVERED In this article, after briefly outlining the risk factors for CAV, the authors revise the potential pharmacological approaches that may reduce the burden of CAV. While several therapies have shown convincing efficacy in terms of CAV prevention diagnosed by coronary imaging, very few have been reported to improve prognosis with any meaningful level of evidence. EXPERT OPINION The authors believe that a customizable approach is necessary for clinical practice given the currently available evidence. Furthermore, it is important, in the future, to address the glaring therapeutic gap of an effective treatment against donor-specific antibodies, whose effect on endothelial injury is currently one of the major mechanisms of CAV development and for which no pharmacological treatment is currently available.
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Affiliation(s)
- Giosafat Spitaleri
- Heart Failure and Heart Transplant Unit, Cardiovascular Institute, Hospital Clínic , Barcelona, Spain
| | - Marta Farrero Torres
- Heart Failure and Heart Transplant Unit, Cardiovascular Institute, Hospital Clínic , Barcelona, Spain
| | - Mario Sabatino
- Heart Failure and Heart Transplant Program, Bologna Academic Hospital , Bologna, Italy
| | - Luciano Potena
- Heart Failure and Heart Transplant Program, Bologna Academic Hospital , Bologna, Italy
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10
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The role of optical coherence tomography and other intravascular imaging modalities in cardiac allograft vasculopathy. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2020; 16:19-29. [PMID: 32368233 PMCID: PMC7189132 DOI: 10.5114/aic.2020.93909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/13/2020] [Indexed: 11/17/2022] Open
Abstract
Orthotopic heart transplantation (OHT) is the standard-of-care for end-stage heart disease. Although a significant improvement in the prognosis of patients after OHT has been observed in recent years, their overall mortality remains relatively high, with a median survival of approximately 10 years after transplantation. One of the primary causes of death in patients after OHT is cardiac allograft vasculopathy (CAV), the condition developing specifically in the coronary vasculature after OHT, the pathophysiology of which is still inadequately known. It is estimated that CAV development and progression is responsible for approximately 30% of deaths within five years post-OHT. According to the International Society for Heart and Lung Transplantation (ISHLT) Nomenclature for CAV, its presence should be assessed primarily by the coronary angiography performed routinely after OHT, mostly due to its wide availability, reproducibility, and low complication rate. However, the analysis of CAV in coronary angiography has limitations, mostly concerning its - sometimes inadequate - sensitivity and specificity. Hence, there is a growing need for the introduction of more accurate methods of CAV assessment, such as intravascular imaging, which through a thorough evaluation of the arterial wall structure and thickness allows the drawbacks of routine angiography to be minimised. The aim of the article was to critically summarise the current findings derived from the analysis of CAV by optical coherence tomography, the other intravascular imaging modalities, such as intravascular ultrasound (IVUS) and IVUS-derived virtual histology, along with physiological assessment with the use of the fractional flow reserve.
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11
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Intravascular Imaging for Assessment of Cardiac Allograft Vasculopathy Following Heart Transplantation. CURRENT CARDIOVASCULAR IMAGING REPORTS 2020. [DOI: 10.1007/s12410-020-9525-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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12
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Liu Y, Li CP, Wang YY, Dong YN, Liu HW, Xiao JY, Gao MD, Wang JX, Li XW, Zhang N, Ma J, Gao J. Prediction of Major Adverse Cardiovascular Events and Slow/No-Reflow by Virtual Histology Imaging After Percutaneous Interventions on Saphenous Vein Grafts. Angiology 2019; 71:263-273. [PMID: 31867979 DOI: 10.1177/0003319719892354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Saphenous vein grafts disease (SVGD) is a common complication after coronary artery bypass graft (CABG) and usually treated by percutaneous coronary intervention (PCI). In this prospective cohort study, we performed virtual histology-intravascular ultrasound to investigate whether plaque composition and morphological characteristics were associated with post-PCI major adverse cardiac events (MACEs) and slow/no-reflow in patients with SVGD. Patients (n = 90) were studied (76.7% men, mean age 64.9 ± 8.2 years and mean duration of SVG 8.0 ± 3.6 years). There were 77.8% lesions with a plaque burden of at least 70%; 18 MACE incidences accumulated in 14 patients over 12 months post-PCI and slow/no-reflow was observed in 12 patients. On adjusted multivariate analysis, lesion length (hazard ratio [HR] = 1.05; 95% confidence interval [CI]: 1.01-1.08]); age of CABG (HR = 1.51 [95% CI: 1.11-2.05], and absolute necrotic core (NC) area (HR = 8.04 [95% CI: 1.86-34.73]) were independently associated with MACEs. Factors independently associated with slow/no-reflow post-PCI were preprocedure systolic blood pressure (odds ratio [OR] = 0.98; 95% CI: 0.96-0.99) and absolute NC area (OR = 2.47 (95% CI: 1.14-5.36). A cutoff value of absolute NC area at ≥1.1 mm2 may serve as a significant risk predictor for no-reflow after SVG-PCI. Factors associated with MACEs and the slow/no-reflow phenomenon following PCI of the SVG can be used in risk assessment of SVG.
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Affiliation(s)
- Yin Liu
- Department of Cardiology, Tianjin Chest Hospital, Jinnan, Tianjin, People's Republic of China
| | - Chang-Ping Li
- Tianjin Medical University, Heping, Tianjin, People's Republic of China
| | - Yue-Ying Wang
- Tianjin Medical University, Heping, Tianjin, People's Republic of China
| | - Ya-Nan Dong
- Tianjin Medical University, Heping, Tianjin, People's Republic of China
| | - Hong-Wei Liu
- Tianjin Medical University, Heping, Tianjin, People's Republic of China
| | - Jian-Yong Xiao
- Department of Cardiology, Tianjin Chest Hospital, Jinnan, Tianjin, People's Republic of China
| | - Ming-Dong Gao
- Department of Cardiology, Tianjin Chest Hospital, Jinnan, Tianjin, People's Republic of China
| | - Ji-Xiang Wang
- Department of Cardiology, Tianjin Chest Hospital, Jinnan, Tianjin, People's Republic of China
| | - Xiao-Wei Li
- Department of Cardiology, Tianjin Chest Hospital, Jinnan, Tianjin, People's Republic of China
| | - Nan Zhang
- Department of Cardiology, Tianjin Chest Hospital, Jinnan, Tianjin, People's Republic of China
| | - Jun Ma
- Tianjin Medical University, Heping, Tianjin, People's Republic of China
| | - Jing Gao
- Cardiovascular Institute, Tianjin Chest Hospital, Jinnan, Tianjin, People's Republic of China
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Application of virtual histological intravascular ultrasound in plaque composition assessment of saphenous vein graft diseases. Chin Med J (Engl) 2019; 132:957-962. [PMID: 30958438 PMCID: PMC6595773 DOI: 10.1097/cm9.0000000000000183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Saphenous vein grafts disease (SVGD) is a common complication after coronary artery bypass graft (CABG) and normally treated by percutaneous coronary intervention (PCI). The most common complication after SVG-PCI is slow or no-reflow. It is known that the no-reflow phenomenon occurs in up to 15% of the SVG-PCI and is associated with high risk of major adverse cardiac events (MACEs) and mortality, therefore, it is important to investigate the factors that could predict the clinical outcome of PCI for risk stratification and guiding interventions. In recent years, the spectral analysis of intravascular ultrasound (IVUS) radiofrequency data (virtual histology-IVUS [VH-IVUS]) has been used to provide quantitative assessment on both plaque compositions and morphologic characteristics. DATA SOURCES The PubMed, Embase, and Central databases were searched for possible relevant studies published from 1997 to 2018 using the following index keywords: "Coronary artery bypass grafting," "Saphenous venous graft disease," "Virtual histology-intravascular ultrasound," "Virtual histology-intravascular ultrasound," and "Percutaneous coronary intervention." STUDY SELECTION The primary references were Chinese and English articles including original studies and literature reviews, were identified and reviewed to summarize the advances in the application of VH-IVUS techniques in situ vascular and venous graft vascular lesions. RESULTS With different plaque components exhibiting a defined spectrum, VH-IVUS can classify atherosclerotic plaque into four types: fibrous tissue (FT), fibro fatty (FF), necrotic core (NC), and dense calcium (DC). The radiofrequency signal is mathematically transformed into a color-coded representation, including lipid, fibrous tissue, calcification, and necrotic core. Several studies have demonstrated the independent relationship between VH-IVUS-defined plaque classification or plaque composition and MACEs, but a significant association between plaque components and no-reflow after PCI in acute coronary syndrome. In recent years, VH-IVUS are applied to assess the plaque composition of SVGD, based on the similarity of pathophysiological mechanisms between coronary artery disease (CAD) and SVGD, further studies with the larger sample size, the long-term follow-up, multicenter clinical trials may be warranted to investigate the relationship between plaque composition of saphenous vein graft (SVG) by VH-IVUS and clinical outcomes in patients with SVGD undergoing PCI. CONCLUSIONS In degenerative SVG lesions, VH-IVUS found that plaque composition was associated with clinical features, future studies need to explore the relationship between VH-IVUS defined atherosclerotic plaque components and clinical outcomes in SVGD patients undergoing PCI, an innovative prediction tool of clinical outcomes can be created.
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14
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Elevated Heart Rate Following Heart Transplantation Is Associated With Increased Graft Vasculopathy and Mortality. J Card Fail 2019; 25:249-256. [DOI: 10.1016/j.cardfail.2019.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/14/2018] [Accepted: 01/18/2019] [Indexed: 12/24/2022]
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15
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Liu Y, Wang HB, Li X, Xiao JY, Wang JX, Reilly KH, Sun B, Gao J. Relationship between plaque composition by virtual histology intravascular ultrasound and clinical outcomes after percutaneous coronary intervention in saphenous vein graft disease patients: study protocol of a prospective cohort study. BMC Cardiovasc Disord 2018; 18:233. [PMID: 30541457 PMCID: PMC6291998 DOI: 10.1186/s12872-018-0975-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 12/03/2018] [Indexed: 12/01/2022] Open
Abstract
Background Plaque composition and morphologic characteristics identified by virtual histology intravascular ultrasound (VH-IVUS) can determine plaques at increased risk of clinical events following percutaneous coronary intervention (PCI) among coronary artery disease (CAD) patients. However, there have been few studies to investigate the relationship between plaque composition of saphenous vein graft (SVG) by VH-IVUS and clinical outcomes in patients with saphenous vein graft disease (SVGD) undergoing PCI. The purpose of this study is to determine whether plaque components and characteristics by VH-IVUS can predict major adverse cardiac events (MACEs) among SVGD patients undergoing PCI. Methods/design This is a prospective cohort study conducted in Tianjin Chest Hospital, China. Participants with SVGD referred for PCI will be invited to participate in this study, and will be followed up at 1, 6, 12, 24 and 36 months post-PCI to assess clinical outcomes. The planned sample size is 175 subjects. We will recruit subjects with SVGD scheduled to receive PCI, aged 18–80 years, with a history of previous coronary artery bypass graft (CABG) surgery more than 1 year ago, and willing to participate in the study and sign informed consent. The composite primary study endpoint is the incidence of MACEs after PCI for SVGD, including death from cardiac causes, non-fatal myocardial infarction, unplanned target lesion revascularization (TLR) and target vessel revascularization (TVR). The primary outcome analysis will be presented as Kaplan-Meier estimates and the primary outcome analysis will be carried out using a Cox proportional hazards regression model. Discussion Once the predictive values of plaque components and characteristics by VH-IVUS on subsequent clinical outcomes are determined among SVGD patients undergoing PCI, an innovative prediction tool of clinical outcomes for SVGD patients undergoing PCI will be created, which may lead to the development of new methods of risk stratification and intervention guidance. Trial registration The study is registered to ClinicalTrials.gov (NCT03175952).
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Affiliation(s)
- Yin Liu
- Department of Cardiology, Tianjin Chest Hospital, No.261 Tai er zhuang Road, Jinnan District, Tianjin, 300222, People's Republic of China
| | - Hai-Bo Wang
- Peking University Clinical Research Institute, Xueyuan Rd 38#, Haidian Dist, Beijing, 100191, People's Republic of China
| | - Xiang Li
- Peking University Clinical Research Institute, Xueyuan Rd 38#, Haidian Dist, Beijing, 100191, People's Republic of China
| | - Jian-Yong Xiao
- Department of Cardiology, Tianjin Chest Hospital, No.261 Tai er zhuang Road, Jinnan District, Tianjin, 300222, People's Republic of China
| | - Ji-Xiang Wang
- Department of Cardiology, Tianjin Chest Hospital, No.261 Tai er zhuang Road, Jinnan District, Tianjin, 300222, People's Republic of China
| | | | - Bo Sun
- Department of Cardiology, Tianjin Chest Hospital, No.261 Tai er zhuang Road, Jinnan District, Tianjin, 300222, People's Republic of China
| | - Jing Gao
- Cardiovascular Institute, Tianjin Chest Hospital, No.261 Tai er zhuang Road, Jinnan District, Tianjin, 300222, People's Republic of China.
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16
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Lee MS, Tadwalkar RV, Fearon WF, Kirtane AJ, Patel AJ, Patel CB, Ali Z, Rao SV. Cardiac allograft vasculopathy: A review. Catheter Cardiovasc Interv 2018; 92:E527-E536. [DOI: 10.1002/ccd.27893] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 08/29/2018] [Indexed: 01/19/2023]
Affiliation(s)
- Michael S. Lee
- Division of Cardiology, UCLA Medical Center Los Angeles California
| | | | - William F. Fearon
- Division of CardiologyStanford University School of Medicine Stanford California
| | - Ajay J. Kirtane
- Division of CardiologyColumbia University Medical Center New York New York
| | - Amisha J. Patel
- Division of CardiologyColumbia University Medical Center New York New York
| | - Chetan B. Patel
- Division of CardiologyDuke University Medical Center Durham North Carolina
| | - Ziad Ali
- Division of CardiologyColumbia University Medical Center New York New York
| | - Sunil V. Rao
- Division of CardiologyDuke University Medical Center Durham North Carolina
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17
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Cote AT, Hosking M, Voss C, Human DG, Sandor GGS, Harris KC. Coronary artery intimal thickening and ventricular dynamics in pediatric heart transplant recipients. CONGENIT HEART DIS 2018; 13:663-670. [DOI: 10.1111/chd.12629] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 05/18/2018] [Accepted: 05/21/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Anita T. Cote
- Department of Pediatrics; University of British Columbia & British Columbia Children’s Hospital Research Institute; Vancouver Canada
- School of Human Kinetics; Trinity Western University; Langley Canada
| | - Martin Hosking
- British Columbia Children’s Hospital, Children’s Heart Centre; Vancouver Canada
| | - Christine Voss
- Department of Pediatrics; University of British Columbia & British Columbia Children’s Hospital Research Institute; Vancouver Canada
- British Columbia Children’s Hospital, Children’s Heart Centre; Vancouver Canada
| | - Derek G Human
- British Columbia Children’s Hospital, Children’s Heart Centre; Vancouver Canada
| | - George G. S. Sandor
- Department of Pediatrics; University of British Columbia & British Columbia Children’s Hospital Research Institute; Vancouver Canada
- British Columbia Children’s Hospital, Children’s Heart Centre; Vancouver Canada
| | - Kevin C. Harris
- Department of Pediatrics; University of British Columbia & British Columbia Children’s Hospital Research Institute; Vancouver Canada
- British Columbia Children’s Hospital, Children’s Heart Centre; Vancouver Canada
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18
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Kobayashi Y, Sudini NL, Rhee JW, Aymami M, Moneghetti KJ, Bouajila S, Kobayashi Y, Kim JB, Schnittger I, Teuteberg JJ, Khush KK, Fearon WF, Haddad F. Incremental Value of Deformation Imaging and Hemodynamics Following Heart Transplantation. JACC-HEART FAILURE 2017; 5:930-939. [DOI: 10.1016/j.jchf.2017.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 10/20/2017] [Indexed: 11/30/2022]
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19
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Abstract
PURPOSE OF REVIEW Cardiac allograft vasculopathy (CAV) is a major limitation to long-term survival after heart transplantation. Innovative new techniques to diagnose CAV have been applied to detect disease. This review will examine the current diagnostic and treatment options available to clinicians for CAV. RECENT FINDINGS Diagnostic modalities addressing the pathophysiology underlying CAV (arterial wall thickening and decreased coronary blood flow) improve diagnostic sensitivity when compared to traditional (angiography and dobutamine stress echocardiography) techniques. SUMMARY Limited options are available to prevent and treat CAV; however, progress has been made in making an earlier and more accurate diagnosis. Future research is needed to identify the optimal time to modify immunosuppression and investigate novel treatments for CAV.
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20
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Wever-Pinzon O, Edwards LB, Taylor DO, Kfoury AG, Drakos SG, Selzman CH, Fang JC, Lund LH, Stehlik J. Association of recipient age and causes of heart transplant mortality: Implications for personalization of post-transplant management—An analysis of the International Society for Heart and Lung Transplantation Registry. J Heart Lung Transplant 2017; 36:407-417. [DOI: 10.1016/j.healun.2016.08.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 07/11/2016] [Accepted: 08/17/2016] [Indexed: 11/28/2022] Open
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21
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Okada K, Fearon WF, Luikart H, Kitahara H, Otagiri K, Tanaka S, Kimura T, Yock PG, Fitzgerald PJ, Yeung AC, Valantine HA, Khush KK, Honda Y. Attenuated-Signal Plaque Progression Predicts Long-Term Mortality After Heart Transplantation: IVUS Assessment of Cardiac Allograft Vasculopathy. J Am Coll Cardiol 2016; 68:382-92. [PMID: 27443435 PMCID: PMC4959008 DOI: 10.1016/j.jacc.2016.05.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 04/04/2016] [Accepted: 05/03/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although cardiac allograft vasculopathy (CAV) is typically characterized by diffuse coronary intimal thickening with pathological vessel remodeling, plaque instability may also play an important role in CAV. Previous studies of native coronary atherosclerosis have demonstrated associations between attenuated-signal plaque (ASP), plaque instability, and adverse clinical events. OBJECTIVES This study's aim was to characterize the association between ASP and long-term mortality post-heart transplantation. METHODS In 105 heart transplant recipients, serial (baseline and 1-year post-transplant) intravascular ultrasound was performed in the first 50 mm of the left anterior descending artery. The ASP score was calculated by grading the measured angle of attenuation from grades 0 to 4 (specifically, 0°, 1° to 90°, 91° to 180°, 181° to 270°, and >270°) at 1-mm intervals. The primary endpoint was all-cause death or retransplantation. RESULTS At 1-year post-transplant, 10.5% of patients demonstrated ASP progression (newly developed or increased ASP). Patients with ASP progression had a higher incidence of acute cellular rejection during the first year (63.6% vs. 22.3%; p = 0.006) and tendency for greater intimal growth (percent intimal volume: 9.2 ± 9.3% vs. 4.4 ± 5.3%; p = 0.07) than those without. Over a median follow-up of 4.6 years, there was a significantly lower event-free survival rate in patients with ASP progression at 1-year post-transplant compared with those without. In contrast, maximum intimal thickness did not predict long-term mortality. CONCLUSIONS ASP progression appears to reflect chronic inflammation related to acute cellular rejection and is an independent predictor of long-term mortality after heart transplantation. Serial assessments of plaque instability may enhance identification of high-risk patients who may benefit from closer follow-up and targeted medical therapies.
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Affiliation(s)
- Kozo Okada
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - William F Fearon
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Helen Luikart
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Hideki Kitahara
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Kyuhachi Otagiri
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Shigemitsu Tanaka
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Takumi Kimura
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Paul G Yock
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Peter J Fitzgerald
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Alan C Yeung
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Hannah A Valantine
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Yasuhiro Honda
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California.
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22
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23
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Ito S, Hasuo T, Nimura Y. iMAP™ imaging of tumorous lesions surrounding the coronary arteries in a patient with an elevated serum level of immunoglobulin G4. Heart Vessels 2016; 31:2061-2067. [DOI: 10.1007/s00380-016-0852-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 05/20/2016] [Indexed: 12/24/2022]
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24
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Loupy A, Toquet C, Rouvier P, Beuscart T, Bories MC, Varnous S, Guillemain R, Pattier S, Suberbielle C, Leprince P, Lefaucheur C, Jouven X, Bruneval P, Duong Van Huyen JP. Late Failing Heart Allografts: Pathology of Cardiac Allograft Vasculopathy and Association With Antibody-Mediated Rejection. Am J Transplant 2016; 16:111-20. [PMID: 26588356 DOI: 10.1111/ajt.13529] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 07/19/2015] [Accepted: 07/20/2015] [Indexed: 01/25/2023]
Abstract
In heart transplantation, there is a lack of robust evidence of the specific causes of late allograft failure. We hypothesized that a substantial fraction of failing heart allografts may be associated with antibody-mediated injury and immune-mediated coronary arteriosclerosis. We included all patients undergoing a retransplantation for late terminal heart allograft failure in three referral centers. We performed an integrative strategy of heart allograft phenotyping by assessing the heart vascular tree including histopathology and immunohistochemistry together with circulating donor-specific antibodies. The main analysis included 40 explanted heart allografts patients and 402 endomyocardial biopsies performed before allograft loss. Overall, antibody-mediated rejection was observed in 19 (47.5%) failing heart allografts including 16 patients (40%) in whom unrecognized previous episodes of subclinical antibody-mediated rejection occurred 4.5 ± 3.5 years before allograft loss. Explanted allografts with evidence of antibody-mediated rejection demonstrated higher endothelitis and microvascular inflammation scores (0.89 ± 0.26 and 2.25 ± 0.28, respectively) compared with explanted allografts without antibody-mediated rejection (0.42 ± 0.11 and 0.36 ± 0.09, p = 0.046 and p < 0.0001, respectively). Antibody-mediated injury was observed in 62.1% of failing allografts with pure coronary arteriosclerosis and mixed (arteriosclerosis and atherosclerosis) pattern, while it was not observed in patients with pure coronary atherosclerosis (p = 0.0076). We demonstrate that antibody-mediated rejection is operating in a substantial fraction of failing heart allografts and is associated with severe coronary arteriosclerosis. Unrecognized subclinical antibody-mediated rejection episodes may be observed years before allograft failure.
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Affiliation(s)
- A Loupy
- Paris Translational Research Center for Organ Transplantation, Paris, France.,University Paris Descartes, Paris, France
| | - C Toquet
- Department of Pathology, Hôpital Laennec, Nantes, France
| | - P Rouvier
- Department of Pathology, Hôpital La Pitié, Paris, France
| | - T Beuscart
- Paris Translational Research Center for Organ Transplantation, Paris, France
| | - M C Bories
- Paris Translational Research Center for Organ Transplantation, Paris, France
| | - S Varnous
- Department of Cardiac Surgery, Hôpital La Pitié, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - R Guillemain
- Cardiothoracic Transplantation Unit, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - S Pattier
- Department of Cardiac Surgery, Hôpital Laennec, Nantes, France
| | - C Suberbielle
- Histocompatibility Laboratory, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - P Leprince
- Department of Cardiac Surgery, Hôpital La Pitié, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - C Lefaucheur
- Paris Translational Research Center for Organ Transplantation, Paris, France
| | - X Jouven
- Paris Translational Research Center for Organ Transplantation, Paris, France.,University Paris Descartes, Paris, France.,Department of Cardiology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - P Bruneval
- Paris Translational Research Center for Organ Transplantation, Paris, France.,University Paris Descartes, Paris, France.,Department of Pathology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - J P Duong Van Huyen
- Paris Translational Research Center for Organ Transplantation, Paris, France.,University Paris Descartes, Paris, France.,Department of Pathology, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
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25
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Okada K, Kitahara H, Yang HM, Tanaka S, Kobayashi Y, Kimura T, Luikart H, Yock PG, Yeung AC, Valantine HA, Fitzgerald PJ, Khush KK, Honda Y, Fearon WF. Paradoxical Vessel Remodeling of the Proximal Segment of the Left Anterior Descending Artery Predicts Long-Term Mortality After Heart Transplantation. JACC-HEART FAILURE 2015; 3:942-52. [DOI: 10.1016/j.jchf.2015.07.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 07/13/2015] [Accepted: 07/17/2015] [Indexed: 12/01/2022]
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26
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Zheng B, Maehara A, Mintz GS, Nazif TM, Waksman Y, Qiu F, Jaquez L, Rabbani LE, Apfelbaum MA, Ali ZA, Dalton K, Song L, Xu K, Marboe CC, Mancini DM, Weisz G. Increased coronary lipid accumulation in heart transplant recipients with prior high-grade cellular rejection: novel insights from near-infrared spectroscopy. Int J Cardiovasc Imaging 2015; 32:225-234. [PMID: 26408106 DOI: 10.1007/s10554-015-0777-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 09/23/2015] [Indexed: 10/23/2022]
Abstract
Cardiac allograft vasculopathy is a major cause of morbidity and mortality among patients after heart transplantation. We sought to assess the amount of lipid accumulation in the coronary arteries of transplant patients according to rejection grade. Overall, 39 consecutive heart transplant recipients undergoing annual routine surveillance coronary angiography underwent near-infrared spectroscopy and intravascular ultrasound imaging of 1 coronary artery. Rejection history was graded according to the International Society of Heart and Lung Transplantation (ISHLT) classification as none/mild/moderate-grade rejection (ISHLT 0, 1A/1B, or 2) compared to high-grade rejection (≥3A). Patients with prior history of high-grade rejection had larger plaque burden in the distal coronary segments [45.7 % (25.5-63.7) vs 25.1 % (19.9-37.8), p = 0.02] and a higher maximum lipid core burden index in any 4-mm long segment (maxLCBI(4mm)) [243 (91-400) vs 41 (1-170), p = 0.016] as compared with patients with prior history of none/mild/moderate-grade rejection. By multivariable linear regression analysis, prior history of high-grade rejection was an independent predictor for maxLCBI(4mm). A maxLCBI(4mm) >200 distinguished prior history of high-grade from none/mild/moderate rejection with a sensitivity of 61.5 % and specificity of 84.6 %. The current study demonstrates that the coronary arteries of post heart-transplant patients with a prior history of high-grade cellular rejection have increasing amounts of lipid-rich plaque. MaxLCBI(4mm) >200 might differentiate patients with previous high-grade cellular rejection from heart transplant recipients with none/mild/moderate-grade rejection.
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Affiliation(s)
- Bo Zheng
- NewYork-Presbyterian/Columbia University Medical Center, New York, NY, USA.,Cardiovascular Research Foundation, New York, NY, USA.,Peking University First Hospital, Peking University Health Science Center, Beijing, China
| | - Akiko Maehara
- NewYork-Presbyterian/Columbia University Medical Center, New York, NY, USA. .,Cardiovascular Research Foundation, New York, NY, USA.
| | - Gary S Mintz
- Cardiovascular Research Foundation, New York, NY, USA
| | - Tamim M Nazif
- NewYork-Presbyterian/Columbia University Medical Center, New York, NY, USA.,Cardiovascular Research Foundation, New York, NY, USA
| | - Yarden Waksman
- NewYork-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Fuyu Qiu
- NewYork-Presbyterian/Columbia University Medical Center, New York, NY, USA.,Cardiovascular Research Foundation, New York, NY, USA
| | - Luz Jaquez
- NewYork-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - LeRoy E Rabbani
- NewYork-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Mark A Apfelbaum
- NewYork-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Ziad A Ali
- NewYork-Presbyterian/Columbia University Medical Center, New York, NY, USA.,Cardiovascular Research Foundation, New York, NY, USA
| | - Kate Dalton
- NewYork-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Lei Song
- NewYork-Presbyterian/Columbia University Medical Center, New York, NY, USA.,Cardiovascular Research Foundation, New York, NY, USA.,Fuwai Hospital, Bejing, China
| | - Ke Xu
- Cardiovascular Research Foundation, New York, NY, USA
| | - Charles C Marboe
- NewYork-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Donna M Mancini
- NewYork-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Giora Weisz
- NewYork-Presbyterian/Columbia University Medical Center, New York, NY, USA.,Cardiovascular Research Foundation, New York, NY, USA.,Department of Cardiology, Shaare Zedek Medical Center, 12 Shmuel (Hans) Beyth Street, Jerusalem, 91031, Israel
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27
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Gupta B, Jacob D, Thompson R. Imaging in patients after cardiac transplantation and in patients with ventricular assist devices. J Nucl Cardiol 2015; 22:617-38. [PMID: 25832983 DOI: 10.1007/s12350-015-0115-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 01/29/2015] [Indexed: 02/06/2023]
Abstract
The field of cardiac imaging and the management of patients with severe heart failure have advanced substantially during the past 10 years. Cardiac transplantation offers the best long-term survival with high quality of life for the patients with end stage heart failure. However, acute cardiac rejection and cardiac allograft vasculopathy (CAV) can occur post cardiac transplantation and these problems necessitate regular surveillance. The short-term success of mechanical circulatory support devices (MCSD), such as ventricular assist devices (VADs), in improving survival and quality of life has led to a dramatic growth of the patient population with these devices. The development of optimal imaging techniques and algorithms to evaluate these advanced heart failure patients is evolving and multimodality non-invasive imaging approaches and invasive techniques are commonly employed. Most of the published studies done in the transplant and VAD population are small, and biased based on the strength of the particular program, and there is a relative lack of published protocols to evaluate these patient groups. Moreover, the techniques of echocardiography, computed tomography (CT), magnetic resonance imaging, and nuclear cardiology have all progressed rapidly in recent years. There is thus a knowledge gap for cardiologists, radiologists, and clinicians, especially regarding surveillance for CAV and ideal imaging approaches for patients with VADs. The purpose of this review article is to provide an overview of different noninvasive imaging modalities used to evaluate patients after cardiac transplantation and for patients with VADs. The review focuses on the role of echocardiography, CT, and nuclear imaging in surveillance for CAV and rejection and on the assessment of ventricular structure and function, myocardial remodeling and complications for VAD patients.
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Affiliation(s)
- Bhanu Gupta
- Department of Cardiology, St. Luke's Mid America Heart Institute, 4330 Wornall Rd, Suite 2000, Kansas City, MO, USA
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28
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Ichibori Y, Ohtani T, Nakatani D, Tachibana K, Yamaguchi O, Toda K, Akasaka T, Fukushima N, Sawa Y, Komuro I, Kotani JI, Sakata Y. Optical coherence tomography and intravascular ultrasound evaluation of cardiac allograft vasculopathy with and without intimal neovascularization. Eur Heart J Cardiovasc Imaging 2015; 17:51-8. [PMID: 25976347 DOI: 10.1093/ehjci/jev110] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 04/08/2015] [Indexed: 11/14/2022] Open
Abstract
AIMS Neovascularization is closely associated with plaque progression in non-heart transplantation subjects; on the other hand, cardiac allograft vasculopathy causes unfavourable outcomes. Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) can provide microscopic assessment in vivo. The aim of this study was to investigate the impact of neovascularization on intimal proliferation. METHODS AND RESULTS Both IVUS and OCT were attempted in 45 consecutive patients during annual catheterization after heart transplantation. There were 115 vessels [28 vessels were catheterized within 8 weeks of heart transplantation (baseline)]. IVUS analysis assessed vessel, luminal, and intimal (vessel-lumen) volume using Simpson's method. Qualitative parameters including microchannel were assessed by OCT. A microchannel was defined as a no-signal tubuloluminal structure with a sharply delineated border considered to represent neovascularization. Microchannel was observed more often in patient who had their heart transplant more than a year prior to the imaging, compared with shorter periods (39.1 vs. 10.7%, P = 0.023). All microchannels were seen in thickness >0.5 mm, and intimal volume index (mm(3)/mm) correlated with frequency of microchannel (r = 0.54, P = 0.04). The risks for microchannels were donor age [odds ratio (OR) 1.11; 95% confidence interval (CI) 1.03-1.22; P = 0.007], cytomegalovirus infection (OR 16.21; 95% CI 1.79-220.09; P = 0.012), diabetes (OR 9.5; 95% CI 1.21-116.10; P = 0.032), LDL-cholesterol (OR 1.07; 95% CI 1.01-1.13; P = 0.010), and intimal volume (OR 2.47; 95% CI 1.13-6.36; P = 0.023). CONCLUSION OCT-identified microchannels increased sharply within the first year and were correlated with intimal volume and coronary risks. This suggests that neovascularization may play an important role in the progression of cardiac allograft vasculopathy.
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Affiliation(s)
- Yasuhiro Ichibori
- Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka 565-0871, Japan
| | - Tomohito Ohtani
- Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka 565-0871, Japan
| | - Daisaku Nakatani
- Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka 565-0871, Japan
| | - Kouichi Tachibana
- Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka 565-0871, Japan
| | - Osamu Yamaguchi
- Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka 565-0871, Japan
| | - Koichi Toda
- Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takashi Akasaka
- Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Norihide Fukushima
- Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Sawa
- Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Issei Komuro
- Cardiovascular Medicine, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Jun-ichi Kotani
- Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka 565-0871, Japan
| | - Yasushi Sakata
- Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka 565-0871, Japan
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29
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Dobutamine stress echocardiography during follow-up surveillance in heart transplant patients: Diagnostic accuracy and predictors of outcomes. J Heart Lung Transplant 2015; 34:710-7. [DOI: 10.1016/j.healun.2014.11.019] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 11/06/2014] [Accepted: 11/12/2014] [Indexed: 11/21/2022] Open
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30
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Guddeti RR, Matsuo Y, Matsuzawa Y, Aoki T, Lerman LO, Kushwaha SS, Lerman A. Clinical Implications of Intracoronary Imaging in Cardiac Allograft Vasculopathy. Circ Cardiovasc Imaging 2015; 8:CIRCIMAGING.114.002636. [DOI: 10.1161/circimaging.114.002636] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Raviteja R. Guddeti
- From the Division of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN (R.R.G., Y.M., Y.M., T.A., S.S.K., A.L.); and Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN (L.O.L.)
| | - Yoshiki Matsuo
- From the Division of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN (R.R.G., Y.M., Y.M., T.A., S.S.K., A.L.); and Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN (L.O.L.)
| | - Yasushi Matsuzawa
- From the Division of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN (R.R.G., Y.M., Y.M., T.A., S.S.K., A.L.); and Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN (L.O.L.)
| | - Tatsuo Aoki
- From the Division of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN (R.R.G., Y.M., Y.M., T.A., S.S.K., A.L.); and Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN (L.O.L.)
| | - Lilach O. Lerman
- From the Division of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN (R.R.G., Y.M., Y.M., T.A., S.S.K., A.L.); and Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN (L.O.L.)
| | - Sudhir S. Kushwaha
- From the Division of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN (R.R.G., Y.M., Y.M., T.A., S.S.K., A.L.); and Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN (L.O.L.)
| | - Amir Lerman
- From the Division of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN (R.R.G., Y.M., Y.M., T.A., S.S.K., A.L.); and Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN (L.O.L.)
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Guddeti RR, Matsuo Y, Matsuzawa Y, Aoki T, Lennon RJ, Lerman LO, Kushwaha SS, Lerman A. Ischemic cardiomyopathy is associated with coronary plaque progression and higher event rate in patients after cardiac transplantation. J Am Heart Assoc 2014; 3:jah3634. [PMID: 25095871 PMCID: PMC4310404 DOI: 10.1161/jaha.114.001091] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Cardiac allograft vasculopathy is the leading cause of graft failure and death in heart transplant (HTx) recipients; however, the association between the etiology of heart failure (ischemic cardiomyopathy [ICM] or non‐ICM) that led to HTx and progression of cardiac allograft vasculopathy, and adverse events after HTx has not been explored. Methods and Results We retrospectively included 165 HTx patients, who were followed‐up with at least 2 virtual histology–intravascular ultrasound examinations after HTx, and grouped them as ICM (n=46) or non‐ICM (n=119). Coronary artery plaque volume was analyzed using virtual histology–intravascular ultrasound, and cardiovascular event data—a composite of myocardial infarction, hospitalization for heart failure and arrhythmia, revascularization, retransplantation, and death including cardiovascular death—were collected from the medical records of all study subjects. ICM patients had significantly higher plaque volume at both first (P=0.040) and follow‐up (P=0.015) intravascular ultrasound examinations. After multivariate adjustment for traditional coronary risk factors, ICM was significantly associated with plaque progression (odds ratio 3.10; CI 1.17 to 9.36; P=0.023). Ten‐year cardiovascular event‐free survival was 50% in ICM patients compared with 84% in non‐ICM patients (log‐rank test P=0.003). In multivariate Cox proportional hazard analysis, ICM was significantly associated with a higher event rate after HTx (hazard ratio 2.02; 95% CI 1.01 to 4.00; P=0.048). Conclusion Our study demonstrates that ischemic etiology of cardiomyopathy prior to HTx may be independently associated with plaque progression and higher event rate after HTx.
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Affiliation(s)
- Raviteja R Guddeti
- Division of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN (R.R.G., Y.M., Y.M., T.A., S.S.K., A.L.)
| | - Yoshiki Matsuo
- Division of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN (R.R.G., Y.M., Y.M., T.A., S.S.K., A.L.)
| | - Yasushi Matsuzawa
- Division of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN (R.R.G., Y.M., Y.M., T.A., S.S.K., A.L.)
| | - Tatsuo Aoki
- Division of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN (R.R.G., Y.M., Y.M., T.A., S.S.K., A.L.)
| | - Ryan J Lennon
- Division of Biomedical Statistics and Informatics, Mayo College of Medicine, Rochester, MN (R.J.L.)
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN (L.O.L.)
| | - Sudhir S Kushwaha
- Division of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN (R.R.G., Y.M., Y.M., T.A., S.S.K., A.L.)
| | - Amir Lerman
- Division of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN (R.R.G., Y.M., Y.M., T.A., S.S.K., A.L.)
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Lin K, Lloyd-Jones DM, Taimen K, Liu Y, Bi X, Li D, Carr JC. The detection of coronary stiffness in cardiac allografts using MR imaging. Eur J Radiol 2014; 83:1402-7. [PMID: 24929442 DOI: 10.1016/j.ejrad.2014.05.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Revised: 11/07/2013] [Accepted: 05/20/2014] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To test the hypothesis that biomechanical changes are quantitatively related to morphological features of coronary arteries in heart transplant (HTx) recipients. MATERIALS AND METHODS With IRB approval, three-dimensional (3D) magnetic resonance (MR) angiography and two-dimensional (2D) black-blood stead-state free precession (SSFP) MR imaging were performed to image coronary arteries of 36 HTx patients. Contours of coronary wall were manually drawn. For each coronary segment, coronary wall thickness, wall area, lumen area (in systole and diastole) were acquired. Coronary distensibility index (CDI) and the percent of the coronary wall occupying the vessel area (PWOV) were calculated. RESULTS There are totally 98 coronary segments eligible for quantitative analysis from 27 HTx patients. The CDI is 4.90 ± 2.44 mmHg(-1). The mean wall thickness is 1.49 ± 0.24 mm and the PWOV is 74.6% ± 7.5%. CDI has moderate correlations with wall thickness (r=-0.531, P<0.001) and with PWOV (R=-0.435, P<0.001). CONCLUSIONS Detected with coronary MR imaging, CDI is quantitatively correlated with the morphological features of the coronary artery in HTx patients. Coronary stiffness has the potential to become an alternative imaging biomarker for the quantitative assessment of the status of cardiac allografts.
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Affiliation(s)
- Kai Lin
- Department of Radiology, Northwestern University, 737 N Michigan Avenue, Suite 1600, Chicago, IL 60611, United States.
| | - Donald M Lloyd-Jones
- Department of Preventive Medicine, Northwestern University, 680 N Lake Shore Drive, Suite 1400, Chicago, IL 60611, United States
| | - Kirsi Taimen
- Department of Radiology, Northwestern University, 737 N Michigan Avenue, Suite 1600, Chicago, IL 60611, United States
| | - Ying Liu
- Department of Radiology, Northwestern University, 737 N Michigan Avenue, Suite 1600, Chicago, IL 60611, United States
| | - Xiaoming Bi
- Cardiovascular MR R&D, Siemens Healthcare, 737 N Michigan Avenue, Suite 1600, Chicago, IL 60611, United States
| | - Debiao Li
- Department of Radiology, Northwestern University, 737 N Michigan Avenue, Suite 1600, Chicago, IL 60611, United States
| | - James C Carr
- Department of Radiology, Northwestern University, 737 N Michigan Avenue, Suite 1600, Chicago, IL 60611, United States
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Coronary cardiac allograft vasculopathy versus native atherosclerosis: difficulties in classification. Virchows Arch 2014; 464:627-35. [PMID: 24807733 DOI: 10.1007/s00428-014-1586-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 04/14/2014] [Accepted: 04/24/2014] [Indexed: 02/01/2023]
Abstract
Cardiac allograft vasculopathy is regarded as a progressive and diffuse intimal hyperplastic lesion of arteries and veins that leads to insidious vessel narrowing and to allograft ischemic disease, such as acute myocardial infarction or sudden cardiac death. The coronary lesions in transplanted hearts are considered as a particular type of arteriosclerosis with many similarities but also significant differences compared to native coronary atherosclerosis. It is particularly difficult for pathologists to systematically classify the lesions and to elucidate their origins, since over time, the allograft immune responses cause vascular pathology characterized by not only the onset of de novo fibrocellular lesions but also remodeling of already-existing native atherosclerotic lesions in the donor heart. Intraplaque hemorrhages, which result from newly formed leaky microvessels, may cause rapid increase of stenosis and generate a substrate for plaque destabilization. Comparing cardiac allograft vasculopathy from explanted hearts at autopsy with native coronary atherosclerosis from hearts removed at transplantation has revealed that ongoing intraplaque hemorrhages are also an important feature of cardiac allograft vasculopathy and may be important factors in the rapid progression of cardiac allograft vasculopathy.
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Dong L, Maehara A, Nazif TM, Pollack AT, Saito S, Rabbani LE, Apfelbaum MA, Dalton K, Moses JW, Jorde UP, Xu K, Mintz GS, Mancini DM, Weisz G. Optical coherence tomographic evaluation of transplant coronary artery vasculopathy with correlation to cellular rejection. Circ Cardiovasc Interv 2014; 7:199-206. [PMID: 24714488 DOI: 10.1161/circinterventions.113.000949] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiac allograft vasculopathy is an accelerated fibroproliferative process that affects the coronary arteries of transplanted hearts. Intracoronary imaging with optical coherence tomography enables detection of subangiographic cardiac allograft vasculopathy. METHODS AND RESULTS At the time of routine surveillance coronary angiography, 48 consecutive heart transplant recipients underwent optical coherence tomographic imaging of 1 coronary artery. Imaging findings were compared per rejection history that was graded according to the International Society of Heart and Lung Transplantation classification as none/mild (International Society of Heart and Lung Transplantation 0, 1A/1B, or 2) or high-grade rejection (≥3A). Compared with the none/mild rejection group (37 patients) using Mann-Whitney U test, patients in the high-grade rejection group (11 patients) had a thicker intima in all coronary segments (distal: 0.22 mm [0.09-0.41] versus 0.09 mm [0.06-0.17], P=0.02; middle: 0.35 mm [0.00-0.45] versus 0.14 mm [0.08-0.24], P=0.002; and proximal: 0.34 mm [0.21-0.44] versus 0.15 mm [0.11-0.21], P=0.005) and a higher prevalence of foamy macrophages (distal: 55% versus 9%, P=0.003; middle: 55% versus 22%, P=0.004; and proximal: 44% versus 13%, P=0.05) using χ(2) statistics. Side branches in the high-grade rejection group had smaller lumen diameters and a higher prevalence of intimal thickening (54% versus 36%; P=0.01). Intimal microvessels were also more prevalent in the high-grade rejection group versus the none/mild rejection group (46% versus 11%; P=0.02). CONCLUSIONS Coronary optical coherence tomographic evaluation revealed that patients with a history of high-grade cellular rejection, compared with those with none/mild rejection, had more coronary artery intimal thickening with macrophage infiltration, involving all coronary segments and side branches. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT01403142.
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Affiliation(s)
- Liang Dong
- From the NewYork Presbyterian Hospital, Columbia University Medical Center, New York, NY (L.D., A.M., T.M.N., A.T.P., S.S., L.E.R., M.A.A., K.D., J.W.M., U.P.J., D.M.M., G.W.); the Cardiovascular Research Foundation, New York, NY (L.D., A.M., S.S., J.W.M., K.X., G.S.M., G.W.); The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, China (L.D.); and Shaare Zedek Medical Center, Jerusalem, Israel (G.W.)
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Benatti RD, Taylor DO. Evolving concepts and treatment strategies for cardiac allograft vasculopathy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 16:278. [PMID: 24346852 DOI: 10.1007/s11936-013-0278-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT The central event in the development of allograft vasculopathy is the inflammatory response to immune-mediated and nonimmune-mediated endothelial damage. This response is characterized by the release of inflammatory cytokines, upregulation of cell-surface adhesion molecules, and subsequent binding of leukocytes. Growth factors stimulate smooth muscle cell proliferation and circulating progenitor cells are recruited to sites of arterial injury leading to neointima formation. Because of its diffuse nature, intravascular ultrasound is more sensitive than angiography for early diagnosis. Proliferation signal inhibitors (PSIs) have the capacity to slow vasculopathy progression by inhibiting smooth muscle cell proliferation, but its side effects profile makes its use as a first line agent difficult. Retransplantation is still the only definitive therapy but is available only in selected cases. The current hope is that immunomodulation at the time of transplant could induce long-term tolerance and graft accommodation, leading to less vasculopathy.
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Affiliation(s)
- Rodolfo Denadai Benatti
- Kaufman Center for Heart Failure, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J3-4 desk, Cleveland, OH, 44195, USA
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Attenuation of cardiac allograft vasculopathy by sirolimus: Relationship to time interval after heart transplantation. J Heart Lung Transplant 2013; 32:784-91. [PMID: 23856215 DOI: 10.1016/j.healun.2013.05.015] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 05/24/2013] [Accepted: 05/29/2013] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The aim of the study was to assess temporal changes in plaque size and components after heart transplantation (HTx), and to evaluate the differences in treatment effects on plaque progression between sirolimus and calcineurin inhibitors (CNIs). METHODS The study comprised 146 HTx recipients who were converted from CNIs to sirolimus as primary immunosuppressant (sirolimus group, n = 61) and those who were maintained on CNIs (CNI group, n = 85). A retrospective compositional analysis of serial virtual histology-intravascular ultrasound was performed. RESULTS During a median follow-up of 2.8 years, there was a significant difference in plaque volume in favor of sirolimus between groups (p = 0.004). When subjects were sub-classified according to the time interval between HTx and study inclusion, those in the early group (≤2 years after HTx) had a greater increase in plaque volume (p = 0.006), characterized by a higher progression rate of fibrous plaque volume (p = 0.01). The treatment difference between groups in plaque volume was identified in the early group in favor of sirolimus with attenuating effects on the progression of fibrous plaque component (both p = 0.03 for interaction). By contrast, there were significant differences in necrotic core and dense calcium volume (both p < 0.05 for interaction) in favor of CNIs in the late group (≥6 years after HTx). CONCLUSIONS Compared with continued CNI therapy, sirolimus attenuated plaque progression in recipients with early conversion, but contributed to increases in necrotic core and dense calcium volume in those with late conversion. Our study supports the hypothesis that early initiation of sirolimus offers greater benefits in the treatment of CAV.
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Tomai F, Adorisio R, De Luca L, Pilati M, Petrolini A, Ghini AS, Parisi F, Pongiglione G, Gagliardi MG. Coronary plaque composition assessed by intravascular ultrasound virtual histology: Association with long-term clinical outcomes after heart transplantation in young adult recipients. Catheter Cardiovasc Interv 2013; 83:70-7. [DOI: 10.1002/ccd.25054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 06/01/2013] [Indexed: 11/07/2022]
Affiliation(s)
- Fabrizio Tomai
- Department of Cardiovascular Sciences; European Hospital; Rome
| | - Rachele Adorisio
- Department of Cardiology; IRCCS Ospedale Pediatrico Bambino Gesù; Rome Italy
| | | | - Mara Pilati
- Department of Cardiology; IRCCS Ospedale Pediatrico Bambino Gesù; Rome Italy
| | | | - Anna S. Ghini
- Department of Cardiovascular Sciences; European Hospital; Rome
| | - Francesco Parisi
- Department of Cardiology; IRCCS Ospedale Pediatrico Bambino Gesù; Rome Italy
| | - Giacomo Pongiglione
- Department of Cardiology; IRCCS Ospedale Pediatrico Bambino Gesù; Rome Italy
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Cassar A, Matsuo Y, Herrmann J, Li J, Lennon RJ, Gulati R, Lerman LO, Kushwaha SS, Lerman A. Coronary atherosclerosis with vulnerable plaque and complicated lesions in transplant recipients: new insight into cardiac allograft vasculopathy by optical coherence tomography. Eur Heart J 2013; 34:2610-7. [PMID: 23801824 DOI: 10.1093/eurheartj/eht236] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
AIMS Cardiac allograft vasculopathy (CAV) is a major limitation to long-term survival following cardiac transplantation. Conventional imaging modalities such as angiography and intravascular ultrasound fail to characterize CAV plaque morphology. Our aim was to characterize CAV in vivo using the high spatial resolution of intracoronary optical coherence tomography (OCT). METHODS AND RESULTS We prospectively enrolled 53 cardiac transplant patients to undergo OCT of the left anterior descending coronary artery (LAD) in addition to annual CAV screening by coronary angiography and intravascular ultrasound (IVUS). The proximal 30 mm of the LAD was divided into three segments of 10 mm each (n = 156). Segments with CAV plaque on IVUS were analysed by OCT for specific CAV morphological characteristics within the framework of three groups according to follow-up time after heart transplantation: (i) 0-3 months (n = 18), (ii) 12-36 months (n = 55), and (iii) ≥48 months (n = 83). The prevalence of atherosclerotic characteristics such as eccentric plaques, calcification, and lipid pools increased from 6, 0, and 6% in group 1 to 78, 42, and 61% in group 3, respectively (all P < 0.001). The prevalence of vulnerable plaque features such as thin-cap fibroatheroma, macrophages, and microchannels increased from 0% in group 1 to 12, 29, and 33% in group 3, respectively (P = 0.19, P = 0.006, and P = 0.003). Complicated coronary lesions such as intimal laceration, intraluminal thrombus, and layered complex plaque increased from 0% in group 1 to 18, 19, and 57% in group 3 (P = 0.009, P < 0.001, and P < 0.001). Plaque rupture was identified in 4% of group 3 segments. CONCLUSION The current study gives new insight into CAV that extends far beyond the current concept of concentric and fibrosing vasculopathy, that is, the development of atherosclerosis with vulnerable plaque and complicated coronary lesions.
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Affiliation(s)
- Andrew Cassar
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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Matsuo Y, Cassar A, Li J, Flammer AJ, Choi BJ, Herrmann J, Gulati R, Lennon RJ, Kang SJ, Maehara A, Kitabata H, Akasaka T, Lerman LO, Kushwaha SS, Lerman A. Repeated episodes of thrombosis as a potential mechanism of plaque progression in cardiac allograft vasculopathy. Eur Heart J 2013; 34:2905-15. [PMID: 23782648 DOI: 10.1093/eurheartj/eht209] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS The pathogenesis of cardiac allograft vasculopathy (CAV) remains complex and may involve multiple mechanisms. We tested the hypothesis that the multilayer (ML) appearance, an intravascular ultrasound (IVUS) finding suggestive of repetitive thrombosis, is associated with plaque progression in heart transplant (HTx) recipients. METHODS AND RESULTS Our study population consisted of 132 HTx recipients undergoing at least two grayscale and virtual histology (VH)-IVUS examinations. A retrospective serial analysis was performed between the first (baseline) and the last (follow-up) IVUS data during a median follow-up of 3.0 years. The subjects were divided into two groups based on the presence of the ML appearance on the baseline IVUS. At baseline, subjects with ML appearance (n = 38) had a longer time elapsed since transplant, larger vessel volume, and larger plaque volume than those without (n = 94) (all P < 0.01). Intraluminal thrombi and plaque ruptures were identified only in subjects with ML appearance (P < 0.01 vs. those without). More subjects with ML appearance at baseline developed subsequent ML formation compared with those without [21 (55%) vs. 22 (23%), P < 0.01] during follow-up. There was an increase in plaque volume, necrotic core volume, and dense calcium volume in subjects with ML appearance (all P < 0.01 vs. those without). Multivariable linear regression analysis showed that ML appearance was a potential predictor of plaque progression (regression coefficient 0.28, 95% CI 0.10-0.45, P < 0.01). CONCLUSIONS The current study demonstrates that a finding of ML appearance, indicative of repeated episodes of mural thrombosis, is not infrequent in asymptomatic HTx recipients and possibly contributes to progression of CAV.
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Affiliation(s)
- Yoshiki Matsuo
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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Kato TS, Cheema FH, Yang J, Kawano Y, Takayama H, Naka Y, Farr M, Lederer DJ, Baldwin MR, Jin Z, Homma S, Mancini DM, Schulze PC. Preoperative serum albumin levels predict 1-year postoperative survival of patients undergoing heart transplantation. Circ Heart Fail 2013; 6:785-91. [PMID: 23674361 DOI: 10.1161/circheartfailure.111.000358] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Serum albumin concentration has been recognized as a marker of nutrition, severity of inflammation, and hepatic function in patients with various chronic diseases. The purpose of this study was to investigate the impact of pretransplant serum albumin concentration on post-transplant outcome in heart transplant recipients. METHODS AND RESULTS Preoperative laboratory variables, including albumin concentration and donor-related information, were obtained from 822 consecutive patients undergoing heart transplant at Columbia University Medical Center between 1999 and 2010. The association between pretransplant albumin concentration and post-transplant 1-year survival was analyzed. Available data from the United Network for Organ Sharing (n=13671) were also analyzed to evaluate the impact of preoperative albumin levels on post-transplant outcome. In our cohort, multivariable analysis revealed that preoperative albumin (mg/dL; hazard ratio, 0.46; P<0.0001) and preoperative total bilirubin (mg/dL; hazard ratio, 1.26; P=0.0002) were associated with post-transplant 1-year mortality. This implied that for every 1 mg/dL increase in albumin concentration, the post-transplant 1-year mortality rate decreased by 54%. The Kaplan-Meier analysis based on our patients cohort and the United Network for Organ Sharing dataset showed lower survival rate at 1-year post-transplant in patients with albumin levels ≤ 3.5 mg/dL compared with those with >3.5 mg/dL (our patients, 91.3 versus 72.4%; P<0.0001; United Network for Organ Sharing, 88.4 versus 84.8%; P<0.0001). CONCLUSIONS Pretransplant serum albumin concentration is a strong prognostic marker for post-transplant survival in heart transplant recipients.
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Affiliation(s)
- Tomoko S Kato
- Division of Cardiology, Columbia University Medical Center, New York, NY 10032, USA
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Combined heart and liver transplant attenuates cardiac allograft vasculopathy compared with isolated heart transplantation. Transplantation 2013; 95:859-65. [PMID: 23364484 DOI: 10.1097/tp.0b013e31827eef7e] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND We evaluated whether combined heart and liver transplant (H+LTx) can protect the heart graft from the development of cardiac allograft vasculopathy using coronary three-dimensional (3D) volumetric intravascular ultrasound (IVUS). METHODS From 2004 to 2009, we identified 24 isolated heart transplant (HTx) and 10 H+LTx recipients in whom two coronary 3D IVUS studies were performed 1 year apart. Baseline 3D IVUS was performed at 0.22 (0.17-1.16) years after transplantation, with follow-up 3D IVUS exams performed after baseline exam (0.96 [0.83-1.08]). RESULTS Rate of plaque volume and plaque index (plaque volume/vessel volume) progression was attenuated in the H+LTx group (0.3±1.1 vs. 1.5±2.9 mm/mm; P=0.08 and 0.01±0.03 vs. 0.1±0.1; P=0.004, respectively). Rejection burden was much lower in the H+LTx patients. Outcome analysis in 66 consecutive patients (56 HTx and 10 H+LTx) was performed irrespective of performance of second coronary IVUS. H+LTx was associated with reduced rate of cardiac events (P=0.04), which remained significant when adjusted for the difference in the primary etiology for heart disease (P=0.05). CONCLUSIONS Our preliminary serial 3D coronary IVUS data show that H+LTx attenuates cardiac allograft vasculopathy by decreasing the rate of plaque volume and plaque index progression and improves coronary-related outcomes. Because of the small numbers and the differences in etiology of heart disease, our data should be interpreted cautiously, and larger clinical trials would be required to recommend H+LTx for improved coronary remodeling.
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Pollack A, Nazif T, Mancini D, Weisz G. Detection and Imaging of Cardiac Allograft Vasculopathy. JACC Cardiovasc Imaging 2013; 6:613-23. [DOI: 10.1016/j.jcmg.2013.03.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 03/18/2013] [Accepted: 03/21/2013] [Indexed: 10/26/2022]
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Seo YH, Lee CS, Yuk HB, Yang DJ, Park HW, Kim KH, Kim WH, Kwon TG, Bae JH. Hypercholesterolemia and in-vivo coronary plaque composition in patients with coronary artery disease: a virtual histology - intravascular ultrasound study. Korean Circ J 2013; 43:23-8. [PMID: 23408780 PMCID: PMC3569563 DOI: 10.4070/kcj.2013.43.1.23] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 08/06/2012] [Accepted: 09/05/2012] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Hypercholesterolemia is a key factor in the development of atherosclerosis. We sought to evaluate the relation between hypercholesterolemia and plaque composition in patients with coronary artery disease. SUBJECTS AND METHODS Study subjects consisted of 323 patients (mean 61.5 years, 226 males) who underwent coronary angiography and virtual histology-intravascular ultrasound examination. Patients were divided into two groups according to total cholesterol level: hypercholesterolemic group (≥200 mg/dL, n=114) and normocholesterolemic group (<200 mg/dL, n=209). RESULTS Hypercholesterolemic patients were younger (59.7±13.3 years vs. 62.6±11.5 years, p=0.036), than normocholesterolemic patients, whereas there were no significant differences in other demographics. Hypercholesterolemic patients had higher corrected necrotic core volume (1.23±0.85 mm(3)/mm vs. 1.02±0.80 mm(3)/mm, p=0.029) as well as percent necrotic core volume (20.5±8.5% vs. 18.0±9.2%, p=0.016) than normocholesterolemic patients. At the minimal lumen area site, percent necrotic core area (21.4±10.5% vs. 18.4±11.3%, p=0.019) and necrotic core area (1.63±1.09 mm(2) vs. 1.40±1.20 mm(2), p=0.088) were also higher than normocholesterolemic patients. Multivariate linear regression analysis showed that total cholesterol level was an independent factor of percent necrotic core volume in the culprit lesion after being adjusted with age, high density lipoprotein-cholesterol , hypertension, diabetes mellitus, smoking and acute coronary syndrome (beta 0.027, 95% confidence interval 0.02-0.053, p=0.037). CONCLUSION Hypercholesterolemia was associated with increased necrotic core volume in coronary artery plaque. This study suggests that hypercholesterolemia plays a role in making plaque more complex, which is characterized by a large necrotic core, in coronary artery disease.
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Affiliation(s)
- Young Hoon Seo
- Division of Cardiology, Heart Center, Konyang University Hospital, Daejeon, Korea
| | - Chung Seop Lee
- Division of Cardiology, Heart Center, Konyang University Hospital, Daejeon, Korea
| | - Hyung Bin Yuk
- Division of Cardiology, Heart Center, Konyang University Hospital, Daejeon, Korea
| | - Dong Ju Yang
- Division of Cardiology, Heart Center, Konyang University Hospital, Daejeon, Korea
| | - Hyun Woong Park
- Division of Cardiology, Heart Center, Konyang University Hospital, Daejeon, Korea
| | - Ki Hong Kim
- Division of Cardiology, Heart Center, Konyang University Hospital, Daejeon, Korea
| | - Wan Ho Kim
- Division of Cardiology, Heart Center, Konyang University Hospital, Daejeon, Korea
| | - Taek-Geun Kwon
- Division of Cardiology, Heart Center, Konyang University Hospital, Daejeon, Korea
| | - Jang-Ho Bae
- Division of Cardiology, Heart Center, Konyang University Hospital, Daejeon, Korea
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Calé R, Rebocho MJ, Aguiar C, Almeida M, Queiroz e Melo J, Silva JA. Diagnosis, prevention and treatment of cardiac allograft vasculopathy. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.repce.2012.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Arora S, Erikstad I, Ueland T, Sigurdardottir V, Ekmehag B, Jansson K, Eiskjaer H, Bøtker HE, Mortensen SA, Saunamaki K, Gude E, Ragnarsson A, Solbu D, Aukrust P, Gullestad L. Virtual histology assessment of cardiac allograft vasculopathy following introduction of everolimus--results of a multicenter trial. Am J Transplant 2012; 12:2700-9. [PMID: 22958738 DOI: 10.1111/j.1600-6143.2012.04234.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In this 12-month multicenter Scandinavian study, 78 maintenance heart transplant (HTx) recipients randomized to everolimus with reduced calcineurin inhibitor (CNI) exposure or continued standard CNI-therapy underwent matched virtual histology (VH) examination to evaluate morphological progression of cardiac allograft vasculopathy (CAV). Parallel measurement of a range of inflammatory markers was also performed. A similar rate of quantitative CAV progression was observed in the everolimus (n = 30) and standard CNI group (n = 48) (plaque index 1.9 ± 3.8% and 1.6 ± 3.9%, respectively; p = 0.65). However, VH analysis revealed a significant increase in calcified (2.4 ± 4.0 vs. 0.3 ± 3.1%; p = 0.02) and necrotic component (6.5 ± 8.5 vs. 1.1 ± 8.6%; p = 0.01) among everolimus patients compared to controls. The increase in necrotic and calcified components was most prominent in everolimus patients with time since HTx >5.1 years and was accompanied by a significant increase in levels of von Willebrand (vWF) factor (p = 0.04) and vascular cell adhesion molecule (VCAM) (p = 0.03). Conversion to everolimus and reduced CNI is associated with a significant increase in calcified and necrotic intimal components and is more prominent in patients with a longer time since HTx. A significant increase in vWF and VCAM accompanied these qualitative changes and the prognostic implication of these findings requires further investigation.
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Affiliation(s)
- S Arora
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway.
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Calé R, Rebocho MJ, Aguiar C, Almeida M, Queiroz E Melo J, Silva JA. [Diagnosis, prevention and treatment of cardiac allograft vasculopathy]. Rev Port Cardiol 2012; 31:721-30. [PMID: 22999223 DOI: 10.1016/j.repc.2012.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 06/14/2012] [Indexed: 10/27/2022] Open
Abstract
The major limitation of long-term survival after cardiac transplantation is allograft vasculopathy, which consists of concentric and diffuse intimal hyperplasia. The disease still has a significant incidence, estimated at 30% five years after cardiac transplantation. It is a clinically silent disease and so diagnosis is a challenge. Coronary angiography supplemented by intravascular ultrasound is the most sensitive diagnostic method. However, new non-invasive diagnostic techniques are likely to be clinically relevant in the future. The earliest possible diagnosis is essential to prevent progression of the disease and to improve its prognosis. A new nomenclature for allograft vasculopathy has been published in July 2010, developed by the International Society for Heart and Lung Transplantation (ISHLT), establishing a standardized definition. Simultaneously, the ISHLT published new guidelines standardizing the diagnosis and management of cardiac transplant patients. This paper reviews contemporary concepts in the pathophysiology, diagnosis, prevention and treatment of allograft vasculopathy, highlighting areas that are the subject of ongoing research.
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Affiliation(s)
- Rita Calé
- Departamento de Cardiologia e Cirurgia Cardiotorácica, Hospital Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal.
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Ferencik M, Brady TJ, Hoffmann U. Computed tomography imaging of cardiac allograft vasculopathy. J Cardiovasc Comput Tomogr 2012; 6:223-31. [DOI: 10.1016/j.jcct.2011.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Revised: 11/13/2011] [Accepted: 11/18/2011] [Indexed: 10/28/2022]
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Topilsky Y, Hasin T, Raichlin E, Boilson BA, Schirger JA, Pereira NL, Edwards BS, Clavell AL, Rodeheffer RJ, Frantz RP, Maltais S, Park SJ, Daly RC, Lerman A, Kushwaha SS. Sirolimus as primary immunosuppression attenuates allograft vasculopathy with improved late survival and decreased cardiac events after cardiac transplantation. Circulation 2011; 125:708-20. [PMID: 22207715 DOI: 10.1161/circulationaha.111.040360] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND We retrospectively analyzed the potential of sirolimus as a primary immunosuppressant in the long-term attenuation of cardiac allograft vasculopathy progression and the effects on cardiac-related morbidity and mortality. METHODS AND RESULTS Forty-five cardiac transplant recipients were converted to sirolimus 1.2 years (0.2, 4.0) after transplantation with complete calcineurin inhibitor withdrawal. Fifty-eight control subjects 2.0 years (0.2, 6.5 years) from transplantation were maintained on calcineurin inhibitors. Age, sex, ejection fraction, and time from transplantation to baseline intravascular ultrasound study were not different (P>0.2 for all) between the groups; neither were secondary immunosuppressants and use of steroids. Three-dimensional intravascular ultrasound studies were performed at baseline and 3.1 years (1.3, 4.6 years) later. Plaque index progression (plaque volume/vessel volume) was attenuated in the sirolimus group (0.7±10.5% versus 9.3±10.8%; P=0.0003) owing to reduced plaque volume in patients converted to sirolimus early (<2 years) after transplantation (P=0.05) and improved positive vascular remodeling (P=0.01) in patients analyzed late (>2 years) after transplantation. Outcome analysis in 160 consecutive patients maintained on 1 therapy was performed regardless of performance of intravascular ultrasound examinations. Five-year survival was improved with sirolimus (97.4±1.8% versus 81.8±4.9%; P=0.006), as was freedom from cardiac-related events (93.6±3.2% versus 76.9±5.5%; P=0.002). CONCLUSIONS Substituting calcineurin inhibitor with sirolimus as primary immunosuppressant attenuates long-term cardiac allograft vasculopathy progression and may improve long-term allograft survival owing to favorable coronary remodeling. Because of the lack of randomization and retrospective nature of our analysis, the differences in outcome should be interpreted cautiously, and prospective clinical trials are required.
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Affiliation(s)
- Yan Topilsky
- Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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49
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Diverse morphologic manifestations of cardiac allograft vasculopathy: A pathologic study of 64 allograft hearts. J Heart Lung Transplant 2011; 30:1044-50. [DOI: 10.1016/j.healun.2011.04.008] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 03/14/2011] [Accepted: 04/20/2011] [Indexed: 11/18/2022] Open
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Abstract
Solid organ transplantation has become the first line of treatment for a growing number of life-threatening pediatric illnesses. With improved survival, research into the long-term outcome of transplant recipients has become important to clinicians. Adherence to medical instructions remains a challenge, particularly in the adolescent population. New immunosuppressant approaches promise to expand organ transplantation in additional directions. Extension of transplantation into replacement of organs such as faces and hands raises complex ethical issues.
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Affiliation(s)
- Margaret L Stuber
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute, David Geffen School of Medicine at UCLA, 760 Westwood Plaza, Room 48-240, Los Angeles, CA 90024-1759, USA.
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