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Kim IC, Starling RC, Khush K, Passano E, Mirocha J, Bernhardt P, Azarbal B, Cheng R, Esmailian F, Mancini D, Patel JK, Sato T, Varnous S, Kobashigawa JA. Ten-year follow-up cohort of the everolimus versus azathioprine multinational prospective study focusing on intravascular ultrasound findings. J Heart Lung Transplant 2024:S1053-2498(24)01779-0. [PMID: 39089607 DOI: 10.1016/j.healun.2024.07.021] [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: 01/02/2024] [Revised: 06/28/2024] [Accepted: 07/23/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND Long-term clinical outcomes of early intravascular ultrasound (IVUS) findings in a prospective cohort of heart transplantation (HTx) patients have not been evaluated. METHODS This study included patients from 20 centers across Europe and North and South America among the original cohort of the RAD B253 study. Among these patients, 91 had paired IVUS images at baseline and 1-year post-transplant: everolimus 1.5 mg group (n = 25), everolimus 1.5 mg group (n = 33), and azathioprine 3.0 group (n = 33). The primary outcome was a composite of cardiovascular death, retransplantation, myocardial infarction (MI), coronary revascularization, and cardiac allograft vasculopathy (CAV) within a 10-year follow-up period. The secondary outcome was all-cause death, cardiovascular death, retransplantation, MI, coronary revascularization, and CAV. Donor disease was defined as baseline maximal intimal thickness (MIT) >0.66 mm, and rapid progression was defined as a change in MIT > 0.59 mm at 1 year. RESULTS Donor disease (46 patients) was associated with a higher incidence of the primary outcome (hazard ratio (HR) 4.444, 95% confidence interval [CI] 1.946-10.146, p < 0.001). Rapid progression (44 patients) was associated with a significantly higher incidence of the primary outcome (HR 2.942, 95% CI 1.383-6.260, p = 0.005). Higher-risk features on IVUS (positive both donor disease and rapid progression) were independently associated with poor clinical outcomes (HR 4.800, 95% CI 1.816-12.684, p = 0.002). CONCLUSIONS An increase in baseline MIT and a change in first-year MIT in IVUS post HTx was associated with poor outcomes up to 10 years. Early IVUS findings can be considered as surrogate endpoints for evaluating long-term outcomes in HTx clinical trials.
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Affiliation(s)
- In-Cheol Kim
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Randall C Starling
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Kiran Khush
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Elizabeth Passano
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - James Mirocha
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Peter Bernhardt
- Department of Research and Development, Novartis Pharma AG, Basel, Switzerland
| | - Babak Azarbal
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Richard Cheng
- Cardiology Division, University of Washington, Seattle, Washington
| | - Fardad Esmailian
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Donna Mancini
- Cardiology Department, Cardiovascular Institute, Mount Sinai Hospital, New York, New York
| | - Jignesh K Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Takuma Sato
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Shaida Varnous
- Department of Thoracic and Cardiovascular Surgery, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Chih S, Tavoosi A, Beanlands RSB. How to use nuclear cardiology to evaluate cardiac allograft vasculopathy. J Nucl Cardiol 2024; 37:101866. [PMID: 38670316 DOI: 10.1016/j.nuclcard.2024.101866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 04/06/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024]
Affiliation(s)
- Sharon Chih
- Heart Failure and Transplantation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - Anahita Tavoosi
- Cardiac Imaging, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Rob S B Beanlands
- Cardiac Imaging, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Jain R, Kittleson MM. Evolutions in Combined Heart-Kidney Transplant. Curr Heart Fail Rep 2024; 21:139-146. [PMID: 38231443 PMCID: PMC10923997 DOI: 10.1007/s11897-024-00646-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 01/18/2024]
Abstract
PURPOSE OF REVIEW This review describes management practices, outcomes, and allocation policies in candidates for simultaneous heart-kidney transplantation (SHKT). RECENT FINDINGS In patients with heart failure and concomitant kidney disease, SHKT confers a survival advantage over heart transplantation (HT) alone in patients with dialysis dependence or an estimated glomerular filtration rate (eGFR) < 40 mL/min/1.73 m2. However, when compared to kidney transplantation (KT) alone, SHKT is associated with worse patient and kidney allograft survival. In September 2023, the United Network of Organ Sharing adopted a new organ allocation policy, with strict eligibility criteria for SHKT and a safety net for patients requiring KT after HT alone. While the impact of the policy change on SHKT outcomes remains to be seen, strategies to prevent and slow development of kidney disease in patients with heart failure and to prevent kidney dysfunction after HT and SHKT are necessary.
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Affiliation(s)
- Rashmi Jain
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, 2nd floor, 8670 Wilshire Boulevard, Los Angeles, CA, 90211, USA
| | - Michelle M Kittleson
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, 2nd floor, 8670 Wilshire Boulevard, Los Angeles, CA, 90211, USA.
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Feist AA, Mariski M, Awdishu L, Bremer M, Yung G, Jung C, Golts E, Afshar K. Sirolimus Long-Term Tolerability and Impact on Kidney Function in Lung Transplantation: A Single-Center Experience. Transplant Proc 2023; 55:2470-2477. [PMID: 37891020 DOI: 10.1016/j.transproceed.2023.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/22/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND After lung transplant, 2 common complications are calcineurin inhibitor (CNI) induced nephrotoxicity and bronchiolitis obliterans syndrome. The objective of this study was to investigate the long-term effects of sirolimus conversion after lung transplantation. METHODS This was a retrospective cohort study of patients who had undergone lung transplantation at a single center from June 2003 to December 2016. We compared patients converted to a sirolimus-based regimen to those maintained on our standard tacrolimus-based regimen. Kidney function, pulmonary function, and immunosuppression concentrations were compared between the groups. Additionally, indications, toxicity monitoring parameters, and discontinuation rates for sirolimus were collected. RESULTS During the study period, 176 of the 205 patients who underwent lung transplants were converted to a sirolimus-containing regimen (86%). The most common reason for sirolimus initiation was impairment of kidney function or CNI-associated neurotoxicity. Sirolimus was initiated at a median of 150 days post-transplantation and continued for a medium time of 5.02 (2.27-7.85) years. Of those patients converted to sirolimus, 39 (22%) had sirolimus subsequently discontinued secondary to an adverse event. No difference in pulmonary function was found between the groups at 1- and 3-years post-transplantation. In the sirolimus group, the median estimated glomerular filtration rate improved by 8.6 mL/min/1.73 m2 at 3 months post-conversion (P < .001), which was maintained at both 1 and 3 years (P = .014 and .025, respectively). CONCLUSION Sirolimus is a viable immunosuppressant option after lung transplant, which successfully allows for the reduction or withdrawal of the CNI, resulting in sustained improvement in kidney function.
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Affiliation(s)
- Ashley A Feist
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC San Diego, La Jolla, California.
| | - Mark Mariski
- Department of Pharmacy, UC San Diego Health, La Jolla, California
| | - Linda Awdishu
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC San Diego, La Jolla, California
| | - Michelle Bremer
- Department of Transplantation, UC San Diego Health, La Jolla, California
| | - Gordon Yung
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, School of Medicine, UC San Diego, La Jolla, California
| | - Chris Jung
- Department of Transplantation, UC San Diego Health, La Jolla, California
| | - Eugene Golts
- Department of Cardiothoracic Surgery, School of Medicine, UC San Diego, La Jolla, California
| | - Kamyar Afshar
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, School of Medicine, UC San Diego, La Jolla, California
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5
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Chang A, Martin KA, Colvin M, Bellumkonda L. Role of ascorbic acid in cardiac allograft vasculopathy. Clin Transplant 2023; 37:e15153. [PMID: 37792313 DOI: 10.1111/ctr.15153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/04/2023] [Accepted: 09/22/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE OF THE REVIEW Cardiac allograft vasculopathy (CAV) is a progressive fibroproliferative disease which occurs after heart transplantation and is associated with significant long-term morbidity and mortality. Currently available strategies including statins, mammalian target of rapamycin (mTOR) inhibitors, and revascularization, have limited overall effectiveness in treating this pathology once the disease process is established. mTOR inhibitors, while effective when used early in the disease process, are not well tolerated, and hence not routinely used in post-transplant care. RECENT DATA Recent work on rodent models have given us a novel mechanistic understanding of effects of ascorbic acid in preventing CAV. TET methyl cytosine dioxygenase2 (TET2) reduces vascular smooth muscle cell (VSMC) apoptosis and intimal thickening. TET2 is repressed by interferon γ (IFNγ) in the setting of CAV. Ascorbic acid has been shown to promote TET2 activity and attenuate allograft vasculopathy in animal models and CAV progression in a small clinical trial. SUMMARY CAV remains a challenging disease process and needs better preventative strategies. Ascorbic acid improves endothelial dysfunction, reduces reactive oxygen species, and prevents development of intimal hyperplasia by preventing smooth muscle cell apoptosis and hyperproliferation. Further large-scale randomized control studies of ascorbic acid are needed to establish the role in routine post-transplant management.
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Affiliation(s)
- Alyssa Chang
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kathleen A Martin
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Monica Colvin
- Division of Cardiology, Department of Medicine, Yale University, New Haven, Connecticut, USA
| | - Lavanya Bellumkonda
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Zhu S, Yu W, Gao J, Xiong J. Wound complications frequency in heart transplant recipients on mammalian target of rapamycin inhibitors: A meta-analysis. Int Wound J 2023; 20:3491-3497. [PMID: 37165731 PMCID: PMC10588318 DOI: 10.1111/iwj.14221] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 04/17/2023] [Accepted: 04/21/2023] [Indexed: 05/12/2023] Open
Abstract
A meta-analysis investigation was executed to measurethe wound complications (WCs) frequency in heart transplant (HT) recipients on mammalian target of rapamycin inhibitors (MTRIs). A comprehensive literature investigation till February 2023 was applied and 978 interrelated investigations were reviewed. The 10 chosen investigations enclosed 2173 individuals with HT were in the chosen investigations' starting point, 1164 of them were utilising MTRIs, and 1009 were utilising control. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were utilised to compute the value of the WCs frequency in HT recipients on MTRIs by the dichotomous approaches and a fixed or random model. MTRIs had significantly higher WCs (OR, 1.53; 95% CI, 1.19-1.98, P = .001) compared with those with control in individuals with HT. MTRIs had significantly higher WCs compared with those with control in individuals with HT. However, care must be exercised when dealing with its values because of the low number of the nominated investigations and the low sample size of some of the nominated investigations for the meta-analysis.
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Affiliation(s)
- Shenyu Zhu
- Department of Thoracic SurgeryFirst Affiliated Hospital of Gannan Medical UniversityGanzhouChina
- Ganzhou Key Lab of Brain Injury & Brain ProtectionGanzhouChina
| | - Wenbo Yu
- The First Clinical Medical College, Gannan Medical UniversityGanzhouChina
| | - Jianfeng Gao
- The First Clinical Medical College, Gannan Medical UniversityGanzhouChina
| | - Jianxian Xiong
- Department of Cardiovascular SurgeryFirst Affiliated Hospital of Gannan Medical UniversityGanzhouChina
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Kittleson MM, Sharma K, Brennan DC, Cheng XS, Chow SL, Colvin M, DeVore AD, Dunlay SM, Fraser M, Garonzik-Wang J, Khazanie P, Korenblat KM, Pham DT. Dual-Organ Transplantation: Indications, Evaluation, and Outcomes for Heart-Kidney and Heart-Liver Transplantation: A Scientific Statement From the American Heart Association. Circulation 2023; 148:622-636. [PMID: 37439224 DOI: 10.1161/cir.0000000000001155] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
Although heart transplantation is the preferred therapy for appropriate patients with advanced heart failure, the presence of concomitant renal or hepatic dysfunction can pose a barrier to isolated heart transplantation. Because donor organ supply limits the availability of organ transplantation, appropriate allocation of this scarce resource is essential; thus, clear guidance for simultaneous heart-kidney transplantation and simultaneous heart-liver transplantation is urgently required. The purposes of this scientific statement are (1) to describe the impact of pretransplantation renal and hepatic dysfunction on posttransplantation outcomes; (2) to discuss the assessment of pretransplantation renal and hepatic dysfunction; (3) to provide an approach to patient selection for simultaneous heart-kidney transplantation and simultaneous heart-liver transplantation and posttransplantation management; and (4) to explore the ethics of multiorgan transplantation.
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Sommerer C, Legendre C, Citterio F, Watarai Y, Oberbauer R, Basic-Jukic N, Han J, Gawai A, Bernhardt P, Chadban S. Cardiovascular Outcomes in De Novo Kidney Transplant Recipients Receiving Everolimus and Reduced Calcineurin Inhibitor or Standard Triple Therapy: 24-month Post Hoc Analysis From TRANSFORM Study. Transplantation 2023; 107:1593-1604. [PMID: 36959121 DOI: 10.1097/tp.0000000000004555] [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: 03/25/2023]
Abstract
BACKGROUND The comparative impact of everolimus (EVR)-based regimens versus standard of care (mycophenolic acid+standard calcineurin inhibitor [MPA+sCNI]) on cardiovascular outcomes in de novo kidney transplant recipients (KTRs) is poorly understood. The incidence of major adverse cardiac events (MACEs) in KTRs receiving EVR+reduced CNI (rCNI) or MPA+sCNI from the TRANSplant eFficacy and safety Outcomes with an eveRolimus-based regiMen study was evaluated. METHODS The incidence of MACE was determined for all randomized patients receiving at least 1 dose of the study drug. Factors associated with MACEs were determined by logistic regression. Risk of MACE out to 3 y post-study was calculated using the Patient Outcome in Renal Transplantation equation. RESULTS MACE occurred in 81 of 1014 (8.0%; EVR+rCNI) versus 89 of 1012 (8.8%; MPA+sCNI) KTRs (risk ratio, 0.91 [95% confidence interval [CI], 0.68-1.21]). The incidence of circulatory death, myocardial infarction, revascularization, or angina was similar between the arms. Incidence of MACE was similar between EVR+rCNI and MPA+sCNI arms with a higher incidence in prespecified risk groups: older age, pretransplant diabetes (15.1% versus 15.9%), statin use (8.5% versus 10.8%), and low estimated glomerular filtration rate (Month 2 estimated glomerular filtration rate <30 versus >60 mL/min/1.73 m 2 ; odds ratio, 2.23 [95% CI, 1.02-4.86]; P = 0.044), respectively. Predicted risk of MACE within 3 y of follow-up did not differ between the treatment arms. CONCLUSIONS Cardiovascular morbidity and mortality were similar between de novo KTRs receiving EVR+rCNI and MPA+sCNI. EVR+rCNI is a viable alternative to the current standard of care in KTRs.
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Affiliation(s)
- Claudia Sommerer
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christophe Legendre
- Department of Adult Kidney Transplantation, Hôpital Necker, Université de Paris, Paris, France
| | - Franco Citterio
- Agostino Gemelli University Polyclinic Foundation, Catholic University of the Sacred Heart, Rome, Italy
| | - Yoshihiko Watarai
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya-City, Aichi, Japan
| | - Rainer Oberbauer
- Department of Nephrology and Dialysis, University Clinic for Internal Medicine III, Medical University Vienna, Vienna, Austria
| | | | - Jackie Han
- Novartis Pharmaceuticals, East Hanover, NJ
| | | | | | - Steve Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney Local Health District, NSW, Australia
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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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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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11
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Nelson J, Alvey N, Bowman L, Schulte J, Segovia M, McDermott J, Te HS, Kapila N, Levine DJ, Gottlieb RL, Oberholzer J, Campara M. Consensus recommendations for use of maintenance immunosuppression in solid organ transplantation: Endorsed by the American College of Clinical Pharmacy, American Society of Transplantation, and the International Society for Heart and Lung Transplantation. Pharmacotherapy 2022; 42:599-633. [DOI: 10.1002/phar.2716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/29/2022] [Accepted: 04/08/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Joelle Nelson
- Department of Pharmacotherapy and Pharmacy Services University Health San Antonio Texas USA
- Pharmacotherapy Education and Research Center University of Texas Health San Antonio San Antonio Texas USA
- Department of Pharmacy, Pharmacotherapy Division, College of Pharmacy The University of Texas at Austin Austin Texas USA
| | - Nicole Alvey
- Department of Pharmacy Rush University Medical Center Chicago Illinois USA
- Science and Pharmacy Roosevelt University College of Health Schaumburg Illinois USA
| | - Lyndsey Bowman
- Department of Pharmacy Tampa General Hospital Tampa Florida USA
| | - Jamie Schulte
- Department of Pharmacy Services Thomas Jefferson University Hospital Philadelphia Pennsylvania USA
| | | | - Jennifer McDermott
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health Grand Rapids Michigan USA
- Department of Medicine, Michigan State University College of Human Medicine Grand Rapids Michigan USA
| | - Helen S. Te
- Liver Transplantation, Center for Liver Diseases, Department of Medicine University of Chicago Medical Center Chicago Illinois USA
| | - Nikhil Kapila
- Department of Transplant Hepatology Duke University Hospital Durham North Carolina USA
| | - Deborah Jo Levine
- Division of Critical Care Medicine, Department of Medicine The University of Texas Health Science Center at San Antonio San Antonio Texas USA
| | - Robert L. Gottlieb
- Baylor University Medical Center and Baylor Scott and White Research Institute Dallas Texas USA
| | - Jose Oberholzer
- Department of Surgery/Division of Transplantation University of Virginia Charlottesville Virginia USA
| | - Maya Campara
- Department of Surgery University of Illinois Chicago Chicago Illinois USA
- Department of Pharmacy Practice University of Illinois Chicago Chicago Illinois USA
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Shahandeh N, Kashiyama K, Honda Y, Nsair A, Ali ZA, Tobis JM, Fearon WF, Parikh RV. Invasive Coronary Imaging Assessment for Cardiac Allograft Vasculopathy: State-of-the-Art Review. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100344. [PMID: 39131933 PMCID: PMC11307976 DOI: 10.1016/j.jscai.2022.100344] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/07/2022] [Accepted: 04/17/2022] [Indexed: 08/13/2024]
Abstract
Heart transplantation is the standard of care treatment for end-stage heart failure. Therapeutic advances including enhanced immunosuppression and aggressive infectious prophylaxis have led to increased life-expectancy following transplantation; however, cardiac allograft vasculopathy (CAV) remains a leading cause of morbidity and mortality. Although coronary angiography is the current guideline-recommended diagnostic modality for invasive CAV screening, it is limited in its ability to detect early and/or diffuse disease. Efforts to improve outcomes for heart transplant recipients with CAV have focused on developing diagnostic tools with greater sensitivity to capture early CAV in order to better understand the pathobiology and implement treatment to slow disease progression sooner after transplant. The contemporary invasive imaging armamentarium for CAV surveillance includes coronary angiography, intravascular ultrasound, and newer technologies including optical coherence tomography and near-infrared spectroscopy. The present review outlines the use of and data in support of these imaging platforms in the CAV arena and highlights the potential advantages and limitations of each of these modalities.
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Affiliation(s)
- Negeen Shahandeh
- Division of Cardiology, University of California Los Angeles, Los Angeles, California
| | - Kuninobu Kashiyama
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Yasuhiro Honda
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Ali Nsair
- Division of Cardiology, University of California Los Angeles, Los Angeles, California
| | - Ziad A. Ali
- DeMatteis Cardiovascular Institute, St Francis Hospital & Heart Center, Roslyn, New York
- Cardiovascular Research Foundation, New York, New York
| | - Jonathan M. Tobis
- Division of Cardiology, University of California Los Angeles, Los Angeles, California
| | - William F. Fearon
- Division of Cardiovascular Medicine, Stanford University and VA Palo Alto Health Care Systems, Stanford, California
| | - Rushi V. Parikh
- Division of Cardiology, University of California Los Angeles, Los Angeles, California
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Konda P, Golamari R, Eisen HJ. Novel Immunosuppression in Solid Organ Transplantation. Handb Exp Pharmacol 2022; 272:267-285. [PMID: 35318509 DOI: 10.1007/164_2021_569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Solid organ transplantation and survival has improved tremendously in the last few decades, much of the success has been attributed to the advancements in immunosuppression. While steroids are being replaced and much of the immunosuppressive strategies focus on steroid free regimens, novel agents have introduced in the induction, maintenance, and treatment of acute rejection phase. MTOR inhibitors have helped with the renal sparing side effect from the calcineurin inhibitors, newer agents such as rituximab have decreased the incidence of donor-specific antibodies which led to decreased incidence of acute rejection reactions. In this chapter we discuss the newer therapies directed specifically for solid organ transplantation.
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Affiliation(s)
- Prasad Konda
- Heart and Vascular Institute, Pennsylvania State University/Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Reshma Golamari
- Department of Hospital Medicine, Pennsylvania State University/Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Howard J Eisen
- Heart and Vascular Institute, Pennsylvania State University/Milton S. Hershey Medical Center, Hershey, PA, USA.
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15
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Abstract
Mechanistic target of rapamycin (mTOR) inhibitors are macrocyclic lactone antibiotics derived from Streptomyces hygroscopicus that prevent T lymphocyte activation and B cell differentiation. Unlike calcineurin inhibitors (CNIs) that inhibit cytokine production, mTOR inhibitors block the cytokine signal transduction to arrest cells in the G1 to S phase. This class of drugs is commonly used for post-transplantation and cancer management because of its immunosuppressive and antiproliferative properties, respectively. The potential uses of mTOR inhibitors are heavily explored because of their impact on cell growth and proliferation. However, mTOR inhibitors have a broad range of effects that can result in adverse reactions, but side effects can occur with other immunosuppressive agents as well. Thus, the performance of mTOR inhibitors is compared to the outcomes and adverse effects of other immunosuppressive drugs or the combination of other immunosuppressants and mTOR inhibitors. Because mTOR regulates many downstream pathways, mTOR inhibitors can affect these pathways to manage various diseases. Sirolimus (rapamycin) is approved by the Food and Drug Administration (FDA) to treat post-renal transplantation and lymphangioleiomyomatosis (LAM). Everolimus is approved by the FDA to treat postmenopausal advanced hormone receptor-positive, HER2-negative breast cancer in women, progressive neuroendocrine tumors of pancreatic origin (PNET), advanced renal cell carcinoma (RCC), renal angiomyolipoma (AML) and tuberous sclerosis complex (TSC), and subependymal giant cell astrocytoma (SEGA) associated with TSC as well as renal and liver transplantation. Temsirolimus is approved by the FDA to treat advanced RCC. Opportunities to use mTOR inhibitors as therapy for other transplantation, metabolic disease, and cancer management are being researched. mTOR inhibitors are often called proliferation signal inhibitors (PSIs) because of their effects on proliferation pathways.
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Affiliation(s)
- Denise Wang
- Mount Sinai Icahn School of Medicine, New York, NY, USA.
| | - Howard J Eisen
- Pennsylvania State University College of Medicine/Milton S. Hershey Medical Center, Hershey, PA, USA
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16
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Pober JS, Chih S, Kobashigawa J, Madsen JC, Tellides G. Cardiac allograft vasculopathy: current review and future research directions. Cardiovasc Res 2021; 117:2624-2638. [PMID: 34343276 PMCID: PMC8783389 DOI: 10.1093/cvr/cvab259] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/02/2021] [Accepted: 07/29/2021] [Indexed: 12/25/2022] Open
Abstract
Cardiac allograft vasculopathy (CAV) is a pathologic immune-mediated remodelling of the vasculature in transplanted hearts and, by impairing perfusion, is the major cause of late graft loss. Although best understood following cardiac transplantation, similar forms of allograft vasculopathy occur in other vascularized organ grafts and some features of CAV may be shared with other immune-mediated vasculopathies. Here, we describe the incidence and diagnosis, the nature of the vascular remodelling, immune and non-immune contributions to pathogenesis, current therapies, and future areas of research in CAV.
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MESH Headings
- Adaptive Immunity
- Animals
- Coronary Artery Disease/epidemiology
- Coronary Artery Disease/immunology
- Coronary Artery Disease/metabolism
- Coronary Artery Disease/pathology
- Coronary Vessels/immunology
- Coronary Vessels/metabolism
- Coronary Vessels/pathology
- Endothelial Cells/immunology
- Endothelial Cells/metabolism
- Endothelial Cells/pathology
- Graft Rejection/epidemiology
- Graft Rejection/immunology
- Graft Rejection/metabolism
- Graft Rejection/pathology
- Graft Survival
- Heart Transplantation/adverse effects
- Humans
- Immunity, Innate
- Muscle, Smooth, Vascular/immunology
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/pathology
- Myocytes, Smooth Muscle/immunology
- Myocytes, Smooth Muscle/metabolism
- Myocytes, Smooth Muscle/pathology
- Risk Factors
- Signal Transduction
- Treatment Outcome
- Vascular Remodeling
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Affiliation(s)
- Jordan S Pober
- Department of Immunobiology, Pathology and Dermatology, Yale School of Medicine, 10 Amistad Street, New Haven CT 06520-8089, USA
| | - Sharon Chih
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Jon Kobashigawa
- Department of Medicine, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Joren C Madsen
- Division of Cardiac Surgery and Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - George Tellides
- Department of Surgery (Cardiac Surgery), Yale School of Medicine, New Haven, CT, USA
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17
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Acharya D, Loyaga-Rendon RY, Chatterjee A, Rajapreyar I, Lee K. Optical Coherence Tomography in Cardiac Allograft Vasculopathy: State-of-the-Art Review. Circ Heart Fail 2021; 14:e008416. [PMID: 34414769 DOI: 10.1161/circheartfailure.121.008416] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiac allograft vasculopathy (CAV) is a challenging complication of heart transplantation. CAV pathophysiology is incompletely understood, standard screening modalities such as angiography have significant limitations, and currently available therapies have only modest efficacy in preventing progression. Optical coherence tomography is a light-based technique that provides microscopic level catheter-based intravascular imaging and has dramatically expanded our understanding of CAV, demonstrating it to be a complex, heterogeneous, and dynamic process. This review covers characteristics and uses of optical coherence tomography, including vessel characterization, serial use to assess progression of disease, guiding percutaneous intervention, and monitoring response to CAV therapies. We also discuss the potential of optical coherence tomography in providing individualized assessment and enable customized CAV therapies, which may lead to improvements in long-term transplant outcomes.
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Affiliation(s)
- Deepak Acharya
- University of Arizona Sarver Heart Center/Banner University Medical Center, Tucson (D.A., A.C., K.L.)
| | | | - Arka Chatterjee
- University of Arizona Sarver Heart Center/Banner University Medical Center, Tucson (D.A., A.C., K.L.)
| | | | - Kwan Lee
- University of Arizona Sarver Heart Center/Banner University Medical Center, Tucson (D.A., A.C., K.L.)
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18
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Spartalis M, Spartalis E, Siasos G. Cardiac allograft vasculopathy after heart transplantation: Pathophysiology, detection approaches, prevention, and treatment management. Trends Cardiovasc Med 2021; 32:333-338. [PMID: 34303800 DOI: 10.1016/j.tcm.2021.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 01/06/2023]
Abstract
Cardiac allograft vasculopathy (CAV) continues to be a significant risk factor for the recipient's long-term survival following heart transplantation. Our knowledge of its etiology is constantly changing as new imaging techniques provide direct insight into the disease's natural history. CAV identification continues to be difficult since symptoms may be varied or nonexistent. Due to the irreversible nature of the disease, early diagnosis is critical to halting development. Prognostic tools and biomarkers have proliferated as a result of advancements in diagnostic techniques. Simultaneously, pharmaceutical advancements have aided in the amelioration of the disease's progressive progression.
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Affiliation(s)
- Michael Spartalis
- Division of Cardiology, San Raffaele University Hospital, 60 Via Olgettina, Milan 20132, Italy.
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research, University of Athens, Medical School, Athens, Greece
| | - Gerasimos Siasos
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Medical School, 11527 Athens, Greece
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19
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Fida N, Tantrachoti P, Guha A, Bhimaraj A. Post-transplant Management in Heart Transplant Recipients: New Drugs and Prophylactic Strategies. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00933-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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20
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Abstract
Heart transplantation is an effective and life-saving therapy for patients with end-stage heart disease. Cardiac allograft vasculopathy (CAV) is a frequent complication after heart transplantation and a leading cause of graft failure and death. The diffuse involvement of the coronary macro- and microvasculature in CAV poses significant challenges for noninvasive imaging surveillance techniques that depend on regional differences in myocardial perfusion or contractility to detect abnormalities. Recent imaging and transplantation guidelines recommend cardiac PET for CAV evaluation. Current evidence demonstrates high diagnostic accuracy of PET myocardial blood flow and myocardial flow reserve quantification for CAV as well as utility for post-transplant patient risk stratification. Multicenter prospective studies are needed to determine optimal PET measures and to define thresholds for diagnostic and prognostic assessment of CAV.
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Affiliation(s)
- Sharon Chih
- Heart Failure and Transplantation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - Christiane C Wiefels
- Cardiac Imaging, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Rob S B Beanlands
- Cardiac Imaging, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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21
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Aleksova N, Brahmbhatt DH, Kiamanesh O, Petropoulos JA, Chang Y, Guyatt G, Chih S, Ross HJ. The effect of antiplatelet therapy on survival and cardiac allograft vasculopathy following heart transplantation: A systematic review and meta-analysis. Clin Transplant 2020; 35:e14125. [PMID: 33068308 DOI: 10.1111/ctr.14125] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/18/2020] [Accepted: 10/10/2020] [Indexed: 11/29/2022]
Abstract
Cardiac allograft vasculopathy (CAV) is mediated by endothelial inflammation, platelet activation and thrombosis. Antiplatelet therapy may prevent the development of CAV. This systematic review and meta-analysis summarizes and appraises the evidence on the effect of antiplatelet therapy after heart transplantation (HT). CENTRAL(Ovid), MEDLINE(Ovid), Embase(Ovid) were searched from inception until April 30, 2020. Outcomes included CAV, all-cause mortality, and CAV-related mortality. Data were pooled using random-effects models. Seven observational studies including 2023 patients, mean age 52 years, 22% female, 47% with ischemic cardiomyopathy followed over a mean 7.1 years proved eligible. All studies compared acetylsalicylic acid (ASA) to no treatment and were at serious risk of bias. Data from 1911 patients in 6 studies were pooled in the meta-analyses. The evidence is very uncertain about the effect of ASA on all-cause or CAV-related mortality. ASA may reduce the development of CAV (RR 0.75, 95% CI: 0.44-1.29) based on very low certainty evidence. Two studies that conducted propensity-weighted analyses showed further reduction in CAV with ASA (HR 0.31, 95% CI: 0.13-0.74). In conclusion, there is limited evidence that ASA may reduce the development of CAV. Definitive resolution of the impact of antiplatelet therapy on CAV and mortality will require randomized clinical trials.
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Affiliation(s)
- Natasha Aleksova
- Ted Rogers Centre for Heart Research at the Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, ON, Canada
| | - Darshan H Brahmbhatt
- Ted Rogers Centre for Heart Research at the Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, ON, Canada.,National Heart & Lung Institute, Imperial College London, London, UK
| | - Omid Kiamanesh
- Ted Rogers Centre for Heart Research at the Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, ON, Canada.,Division of Cardiology, University of Calgary, Calgary, AB, Canada
| | | | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Sharon Chih
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Heather J Ross
- Ted Rogers Centre for Heart Research at the Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, ON, Canada
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22
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Orban M, Ulrich S, Dischl D, von Samson-Himmelstjerna P, Schramm R, Tippmann K, Hein-Rothweiler R, Strüven A, Lehner A, Braun D, Hausleiter J, Jakob A, Fischer M, Hagl C, Haas N, Massberg S, Mehilli J, Robert DP. Cardiac allograft vasculopathy: Differences of absolute and relative intimal hyperplasia in children versus adults in optical coherence tomography. Int J Cardiol 2020; 328:227-234. [PMID: 33316256 DOI: 10.1016/j.ijcard.2020.12.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/01/2020] [Accepted: 12/04/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Intracoronary imaging enables an early detection of intimal changes. To what extend the development of absolute and relative intimal hyperplasia in intracoronary imaging differs depending on age and post-transplant time is not known. METHODS Aim of our retrospective study was to compare findings between 24 pediatric (cohort P) and 21 adult HTx patients (cohort A) using optical coherence tomography (OCT) at corresponding post-transplant intervals (≤5 years: P1 (n = 11) and A1 (n = 10); >5 and ≤ 10 years: P2 (n = 13) and A2 (n = 11),. Coronary intima thickness (IT), media thickness (MT) and intima to media ratio (I/M) were assessed per quadrant. Maximal IT >0.3 mm was considered absolute, I/M > 1 relative intimal hyperplasia. RESULTS Compared to A1, I/M was significantly higher in P1 (maximal I/M: P1: 5.41 [2.81-13.39] vs. A1: 2.30 [1.55-3.62], p = 0.005), whereas absolute IT values were comparable. In contrast, I/M was comparable between P2 and A2, but absolute IT were significantly higher in A2 (maximal IT: P2: 0.16 mm [0.11-0.25] vs. A2: 0.40 mm [0.30-0.71], p < 0.001). A2 presented with higher absolute IT (maximal: A1: 0.16 mm [0.12-0.44] vs. A2: 0.40 mm [0.30-0.71], p = 0.02) and I/M (maximal I/M A1: 2.30 [1.55-3.62] vs. A2: 3.79 [3.01-5.62], p = 0.04). CONCLUSION Our results suggest an age- and time-dependent difference in the prevalence of absolute and relative intimal hyperplasia in OCT, with an early peak in children and a progressive increase in adults.
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Affiliation(s)
- Madeleine Orban
- Department of Cardiology, Ludwig-Maximilians-University, Klinikum Großhadern, Munich, Germany; Partner Site Munich Heart Alliance, German Centre for Cardiovascular Research (DZHK), Germany.
| | - Sarah Ulrich
- Department of Pediatric Cardiology and Intensive Care Medicine, Ludwig-Maximilians-University, Klinikum Großhadern, Munich, Germany
| | - Dominic Dischl
- Department of Cardiology, Ludwig-Maximilians-University, Klinikum Großhadern, Munich, Germany
| | | | - René Schramm
- Department of Heart Surgery, Ludwig-Maximilians-University, Klinikum Großhadern, Munich, Germany
| | - Katharina Tippmann
- Department of Cardiology, Ludwig-Maximilians-University, Klinikum Großhadern, Munich, Germany
| | - Ralph Hein-Rothweiler
- Department of Cardiology, Ludwig-Maximilians-University, Klinikum Großhadern, Munich, Germany
| | - Anna Strüven
- Department of Cardiology, Ludwig-Maximilians-University, Klinikum Großhadern, Munich, Germany
| | - Anja Lehner
- Department of Pediatric Cardiology and Intensive Care Medicine, Ludwig-Maximilians-University, Klinikum Großhadern, Munich, Germany
| | - Daniel Braun
- Department of Cardiology, Ludwig-Maximilians-University, Klinikum Großhadern, Munich, Germany
| | - Jörg Hausleiter
- Department of Cardiology, Ludwig-Maximilians-University, Klinikum Großhadern, Munich, Germany; Partner Site Munich Heart Alliance, German Centre for Cardiovascular Research (DZHK), Germany
| | - Andre Jakob
- Department of Pediatric Cardiology and Intensive Care Medicine, Ludwig-Maximilians-University, Klinikum Großhadern, Munich, Germany
| | - Marcus Fischer
- Department of Pediatric Cardiology and Intensive Care Medicine, Ludwig-Maximilians-University, Klinikum Großhadern, Munich, Germany
| | - Christian Hagl
- Department of Heart Surgery, Ludwig-Maximilians-University, Klinikum Großhadern, Munich, Germany; Partner Site Munich Heart Alliance, German Centre for Cardiovascular Research (DZHK), Germany
| | - Nikolaus Haas
- Department of Pediatric Cardiology and Intensive Care Medicine, Ludwig-Maximilians-University, Klinikum Großhadern, Munich, Germany
| | - Steffen Massberg
- Department of Cardiology, Ludwig-Maximilians-University, Klinikum Großhadern, Munich, Germany; Partner Site Munich Heart Alliance, German Centre for Cardiovascular Research (DZHK), Germany
| | - Julinda Mehilli
- Department of Cardiology, Ludwig-Maximilians-University, Klinikum Großhadern, Munich, Germany; Partner Site Munich Heart Alliance, German Centre for Cardiovascular Research (DZHK), Germany
| | - Dalla Pozza Robert
- Department of Pediatric Cardiology and Intensive Care Medicine, Ludwig-Maximilians-University, Klinikum Großhadern, Munich, Germany
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23
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Guglin M, Omar HR. Right Atrial Pressure Predicts Mortality Among LVAD Recipients: Analysis of the INTERMACS Database. Heart Lung Circ 2020; 30:592-599. [PMID: 33229240 DOI: 10.1016/j.hlc.2020.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 09/03/2020] [Accepted: 10/16/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Risk stratifying candidates for left ventricular assist device (LVAD) is challenging. While INTERMACS profiles provide some prognostic insights, there is an ongoing search for better tools. We studied pre-LVAD haemodynamic parameters in predicting post-LVAD mortality. METHODS We analysed the INTERMACS dataset for the ability of right atrial pressure (RAP), pulmonary capillary wedge pressure (PCWP), pulmonary arterial systolic (PASP) and diastolic pressures (PADP), mean pulmonary artery pressure, transpulmonary gradient, cardiac output, cardiac power output and INTERMACS profiles, all recorded before LVAD implantation, to predict mortality. RESULTS Among 18,733 patients in the INTERMACS dataset, we found that, RAP was the main significant haemodynamic predictor of mortality (13.1 vs. 14.4 mmHg in survivors and non-survivors, respectively, p<0.001), and a higher RAP also predicted the need for extra-corporeal membrane oxygenation (ECMO) support (p<0.001) and intra-aortic balloon pump (p<0.001). Right atrial pressure had a significantly higher area under the curve (AUC) in predicting mortality compared with PASP (difference between areas 0.0338, p<0.0001), PADP (difference between areas 0.0414, p<0.0001), PCWP (difference between areas 0.0290, p=0.0001) and pulmonary artery pulsatility index (difference between areas 0.0105, p=0.0052). Kaplan Meier survival curves showed that RAP≥13 mmHg was the optimal cut-off value to predict mortality (log-rank p<0.001). On Cox regression analysis, RAP remained an independent predictor of mortality (hazard ratio 1.008, 95% confidence interval 1.003-1.013, p=0.003) after covariate adjustment. According to time of death, a higher RAP remained a significant predictor of mortality at 1 month, 3 months, 6 months, 1 year, and beyond 1 year (all p<0.001). RAP remained a predictor for mortality within INTERMACS profiles. After excluding early deaths (first 3 months), the RAP remained a significant predictor of mortality, while INTERMACS profiles were no longer significant. CONCLUSIONS In general, haemodynamic variables, as well as other criteria including INTERMACS profiles, are weak predictors of mortality. Right atrial pressure is the main consistent haemodynamic predictor of mortality in LVAD recipients. It outperforms other haemodynamic parameters, and keeps its value within each INTERMACS profile.
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Affiliation(s)
- Maya Guglin
- Division of Cardiovascular Medicine, Krannert Institute of Cardiology, Indiana University, Indianapolis, IN, USA.
| | - Hesham R Omar
- Division of Internal Medicine, Swedish American Hospital, Rockford, IL, USA
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24
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Assessment of late-term progression of cardiac allograft vasculopathy in patients with orthotopic heart transplantation using quantitative cardiac 82Rb PET. Int J Cardiovasc Imaging 2020; 37:1461-1472. [PMID: 33123937 DOI: 10.1007/s10554-020-02086-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 10/23/2020] [Indexed: 10/23/2022]
Abstract
The risk stratification and long-term survival of patients with orthotopic heart transplantation (OHT) is impacted by the complication of cardiac allograft vasculopathy (CAV). This study evaluates changes in myocardial blood flow (MBF) and myocardial coronary flow reserve (CFR) in a group of long-term OHT patients using quantitative cardiac 82Rb-positron emission tomography (PET). Twenty patients (7 females and 13 males, mean age = 72.7 ± 12.2 years with CAV and 62.9 ± 7.2 years without CAV and post-OHT mean time = 13.9 years), were evaluated retrospectively using dynamic cardiac 82Rb-PET at rest and regadenoson-induced stress. The patients also underwent selective coronary angiography (SCA) for diagnosis and risk stratification. CAV was diagnosed based on SCA findings and maximal intimal thickness greater than 0.5 mm, as defined by International Society of Heart and Lung Transplantation (ISHLT). Global and regional MBFs were estimated in three vascular territories using the standard 1-tissue compartment model for dynamic 82Rb-PET. The myocardial CFR was also calculated as the ratio of peak stress MBF to rest MBF. Among twenty patients, seven had CAV in, at least, one major coronary artery (ISHLT CAV grade 1 or higher) while 13 patients did not have CAV (NonCAV). Mean rate-pressure products (RPP) at rest were significantly elevated in CAV patients compared to those without CAV (P = 0.002) but it was insignificant at stress (P = NS). There was no significant difference in the stress MBFs between CAV and NonCAV patients (P = NS). However, the difference in RPP-normalized stress MBFs was significant (P = 0.045), while RPP-normalized MBFs at rest was not significant (P = NS). Both CFR and RPP-normalized CFR were significantly lower in CAV compared to NonCAV patients (P < 0.001). There were significant correlations between MBFs and RPPs at rest for both CAV (ρ = 0.764, P = 0.047) and NonCAV patients (ρ = 0.641, P = 0.017), while there were no correlations at stress for CAV (ρ = 0.232, P = NS) and NonCAV patients (ρ = 0.068, P = NS). This study indicates that the resting MBF is higher in late-term post-OHT patients. The high resting MBF and reduced CFR suggest an unprecedented demand of blood flow and blunted response to stress due to impaired vasodilatory capacity that is exacerbated by the presence of CAV.
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25
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Moayedi Y, Fan CPS, Tremblay-Gravel M, Miller RJH, Kawana M, Henricksen E, Parizo J, Wainwright R, Fearon WF, Ross HJ, Khush KK, Teuteberg JJ. Risk factors for early development of cardiac allograft vasculopathy by intravascular ultrasound. Clin Transplant 2020; 34:e14098. [DOI: 10.1111/ctr.14098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 08/26/2020] [Accepted: 08/28/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Yasbanoo Moayedi
- Section of Heart Failure Cardiac Transplant, and Mechanical Circulatory Support Department of Medicine Stanford University Stanford CA USA
- Ted Rogers Centre of Excellence for Heart Research Peter Munk Cardiac Centre University Health Network Toronto Canada
| | - Chun Po S. Fan
- Ted Rogers Centre of Excellence for Heart Research Peter Munk Cardiac Centre University Health Network Toronto Canada
| | - Maxime Tremblay-Gravel
- Section of Heart Failure Cardiac Transplant, and Mechanical Circulatory Support Department of Medicine Stanford University Stanford CA USA
| | - Robert J. H. Miller
- Section of Heart Failure Cardiac Transplant, and Mechanical Circulatory Support Department of Medicine Stanford University Stanford CA USA
| | - Matsaka Kawana
- Section of Heart Failure Cardiac Transplant, and Mechanical Circulatory Support Department of Medicine Stanford University Stanford CA USA
| | - Erik Henricksen
- Section of Heart Failure Cardiac Transplant, and Mechanical Circulatory Support Department of Medicine Stanford University Stanford CA USA
| | - Justin Parizo
- Section of Heart Failure Cardiac Transplant, and Mechanical Circulatory Support Department of Medicine Stanford University Stanford CA USA
| | - Rebecca Wainwright
- Section of Heart Failure Cardiac Transplant, and Mechanical Circulatory Support Department of Medicine Stanford University Stanford CA USA
| | - William F. Fearon
- Division of Cardiovascular Medicine Department of Medicine Stanford University School of Medicine Stanford USA
| | - Heather J. Ross
- Ted Rogers Centre of Excellence for Heart Research Peter Munk Cardiac Centre University Health Network Toronto Canada
| | - Kiran K. Khush
- Section of Heart Failure Cardiac Transplant, and Mechanical Circulatory Support Department of Medicine Stanford University Stanford CA USA
| | - Jeffrey J. Teuteberg
- Section of Heart Failure Cardiac Transplant, and Mechanical Circulatory Support Department of Medicine Stanford University Stanford CA USA
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26
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Chih S, McDonald M, Dipchand A, Kim D, Ducharme A, Kaan A, Abbey S, Toma M, Anderson K, Davey R, Mielniczuk L, Campbell P, Zieroth S, Bourgault C, Badiwala M, Clarke B, Belanger E, Carrier M, Conway J, Doucette K, Giannetti N, Isaac D, MacArthur R, Senechal M. Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement on Heart Transplantation: Patient Eligibility, Selection, and Post-Transplantation Care. Can J Cardiol 2020; 36:335-356. [PMID: 32145863 DOI: 10.1016/j.cjca.2019.12.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/17/2022] Open
Abstract
Significant practice-changing developments have occurred in the care of heart transplantation candidates and recipients over the past decade. This Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement provides evidence-based, expert panel recommendations with values and preferences, and practical tips on: (1) patient selection criteria; (2) selected patient populations; and (3) post transplantation surveillance. The recommendations were developed through systematic review of the literature and using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The evolving areas of importance addressed include transplant recipient age, frailty assessment, pulmonary hypertension evaluation, cannabis use, combined heart and other solid organ transplantation, adult congenital heart disease, cardiac amyloidosis, high sensitization, and post-transplantation management of antibodies to human leukocyte antigen, rejection, cardiac allograft vasculopathy, and long-term noncardiac care. Attention is also given to Canadian-specific management strategies including the prioritization of highly sensitized transplant candidates (status 4S) and heart organ allocation algorithms. The focus topics in this position statement highlight the increased complexity of patients who undergo evaluation for heart transplantation as well as improved patient selection, and advances in post-transplantation management and surveillance that have led to better long-term outcomes for heart transplant recipients.
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Affiliation(s)
- Sharon Chih
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - Michael McDonald
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Anne Dipchand
- Labatt Family Heart Centre, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Kim
- University of Alberta, Edmonton, Alberta, Canada
| | - Anique Ducharme
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Susan Abbey
- Centre for Mental Health, University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Mustafa Toma
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Kim Anderson
- Halifax Infirmary, Department of Medicine-Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ryan Davey
- University of Western Ontario, London, Ontario, Canada
| | - Lisa Mielniczuk
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | - Christine Bourgault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec
| | - Mitesh Badiwala
- Peter Munk Cardiac Centre, University Health Network and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Michel Carrier
- Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jennifer Conway
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Debra Isaac
- University of Calgary, Calgary, Alberta, Canada
| | | | - Mario Senechal
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), Université Laval, Laval, Québec, Canada
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Everolimus Initiation With Early Calcineurin Inhibitor Withdrawal in De Novo Heart Transplant Recipients: Long-term Follow-up From the Randomized SCHEDULE Study. Transplantation 2020; 104:154-164. [PMID: 30893292 DOI: 10.1097/tp.0000000000002702] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND A calcineurin inhibitor (CNI)-free immunosuppressive regimen has been demonstrated to improve renal function early after heart transplantation, but long-term outcome of such a strategy has not been well described. METHODS In the randomized SCHEDULE trial, de novo heart transplant recipients received (1) everolimus with reduced-exposure CNI (cyclosporine) followed by CNI withdrawal at week 7-11 posttransplant or (2) standard-exposure cyclosporine, both with mycophenolate mofetil and corticosteroids; 95/115 randomized patients were followed up at 5-7 years posttransplant. RESULTS Mean measured glomerular filtration rate was 74.7 mL/min and 62.4 mL/min with everolimus and CNI, respectively. The mean difference was in favor of everolimus by 11.8 mL/min in the intent-to-treat population (P = 0.004) and 17.2 mL/min in the per protocol population (n = 75; P < 0.001). From transplantation to last follow-up, the incidence of biopsy-proven acute rejection (BPAR) was 77% (37/48) and 66% (31/47) (P = 0.23) with treated BPAR in 50% and 23% (P < 0.01) in the everolimus and CNI groups, respectively; no episode led to hemodynamic compromise. Coronary allograft vasculopathy (CAV) assessed by coronary intravascular ultrasound was present in 53% (19/36) and 74% (26/35) of everolimus- and CNI-treated patients, respectively (P = 0.037). Graft dimensions and function were similar between the groups. Late adverse events were comparable. CONCLUSIONS These results suggest that de novo heart transplant patients randomized to everolimus and low-dose CNI followed by CNI-free therapy maintain significantly better long-term renal function as well as significantly reduced CAV than patients randomized to standard CNI treatment. Increased BPAR in the everolimus group during year 1 did not impair long-term graft function.
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Bhagra S, Parameshwar J. Outcomes following cardiac transplantation in adults. Indian J Thorac Cardiovasc Surg 2020; 36:166-174. [DOI: 10.1007/s12055-019-00796-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/10/2019] [Accepted: 01/16/2019] [Indexed: 10/27/2022] Open
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29
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Auerbach SR, Fenton MJ, Grutter G, Albert DC, Di-Filippo S, Burch M, Kuhn MA. The complication rate of intravascular ultrasound (IVUS) in a multicenter pediatric heart transplant population: A study of the international pediatric IVUS consortium. Clin Transplant 2020; 34:e13981. [PMID: 32720750 DOI: 10.1111/ctr.13981] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/26/2020] [Accepted: 05/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Our purpose was to determine the complication rate from intravascular ultrasound (IVUS) in a large, multicenter cohort of pediatric heart transplant (PHT) patients. METHODS We retrospectively reviewed all PHT who underwent IVUS at 5 institutions (2006-2014). Rates of major and minor complications were calculated. All adverse events (AE) were graded from 1 to 5 using a previously published AE severity scale. RESULTS There were 1380 catheterizations in 505 patients and 32 AE (2.3%); 9 major (0.6%) and 23 AE (1.7%). The major AE attributed to IVUS were all coronary artery vasospasm (7). Major and minor AE rates directly related to IVUS were 0.5% and 0.7%, respectively. Minor AE possibly attributable to IVUS included excessive fluoroscopy (3) and transient ST segment changes (7). Of AE related to IVUS, only 3 were of moderate severity. The rest were ≤ minor in severity. There were no reports of coronary artery dissection or death. CONCLUSION Most AE during routine PHT coronary evaluation with IVUS were minor and not directly related to the use of IVUS. The number of coronary related AE was similar to a registry-based report of coronary angiography alone. Efforts to minimize IVUS-related complications should be focused on preventing coronary artery vasospasm.
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Affiliation(s)
- Scott R Auerbach
- Department of Pediatrics, Division of Cardiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Matthew J Fenton
- Paediatric Cardiology, King's College London, London, UK.,Great Ormond Street Hospital, London, UK
| | - Giorgia Grutter
- Pediatric Cardiology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Dimpna C Albert
- Pediatric Cardiology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Sylvie Di-Filippo
- Paediatric Cardiology, Hôpital Cardiologique Louis Pradel, Lyon, France
| | - Michael Burch
- Paediatric Cardiology, King's College London, London, UK.,Great Ormond Street Hospital, London, UK
| | - Michael A Kuhn
- Division of Pediatric Cardiology, Loma Linda University Children's Hospital and Medical Center, Loma Linda, California, USA
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30
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Miller RJH, Kwiecinski J, Shah KS, Eisenberg E, Patel J, Kobashigawa JA, Azarbal B, Tamarappoo B, Berman DS, Slomka PJ, Kransdorf E, Dey D. Coronary computed tomography-angiography quantitative plaque analysis improves detection of early cardiac allograft vasculopathy: A pilot study. Am J Transplant 2020; 20:1375-1383. [PMID: 31758640 DOI: 10.1111/ajt.15721] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/30/2019] [Accepted: 11/15/2019] [Indexed: 01/25/2023]
Abstract
Cardiac allograft vasculopathy (CAV) is an increasingly important complication after cardiac transplant. We assessed the additive diagnostic benefit of quantitative plaque analysis in patients undergoing coronary computed tomography-angiography (CCTA). Consecutive patients undergoing CCTA for CAV surveillance were identified. Scans were visually interpreted for coronary stenosis. Semiautomated software was used to quantify noncalcified plaque (NCP), as well as its components. Optimal diagnostic cut-offs for CAV, with coronary angiography as gold standard, were defined using receiver operating characteristic curves. In total, 36 scans were identified in 17 patients. CAV was present in 17 (46.0%) reference coronary angiograms, at a median of 1.9 years before CCTA. Median NCP (147 vs 58, P < .001), low-density NCP (median 4.5 vs 0.9, P = .003), fibrous plaque (median 76.1 vs 31.1, P = .003), and fibrofatty plaque (median 63.6 vs 27.6, P < .001) volumes were higher in patients with CAV, whereas calcified plaque was not (median 0.0 vs 0.0, P = .510). Visual assessment of CCTA alone was 70.6% sensitive and 100% specific for CAV. The addition of total NCP volume increased sensitivity to 82.4% while maintaining 100% specificity. NCP volume is significantly higher in patients with CAV. The addition of quantitative analysis to visual interpretation improves the sensitivity for detecting CAV without reducing specificity.
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Affiliation(s)
- Robert J H Miller
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA.,Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jacek Kwiecinski
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA.,Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Kevin S Shah
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Evann Eisenberg
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Babak Azarbal
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Balaji Tamarappoo
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Daniel S Berman
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Piotr J Slomka
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Evan Kransdorf
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Damini Dey
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Miller L, Birks E, Guglin M, Lamba H, Frazier OH. Use of Ventricular Assist Devices and Heart Transplantation for Advanced Heart Failure. Circ Res 2020; 124:1658-1678. [PMID: 31120817 DOI: 10.1161/circresaha.119.313574] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
There are only 2 treatments for the thousands of patients who progress to the most advanced form of heart failure despite the application of guideline-based medical therapy, use of ventricular assist devices and heart transplantation. There has been a great deal of progress in both of these therapies that have led to improved outcomes including significant improvement in survival and functional capacity. Heart transplantation offers the best short- and long-term survival for patients with end-stage heart failure, and the majority of these recipients achieve relatively limitless functional capacity for their age. However, the chronic shortage of available donors limits the number of recipients in the United States to an only 2500 patients/y or only a fraction of potential candidates. The significant improvement in outcomes now possible with durable ventricular assist devices has led to a significant increase in their use, which now exceeds the volume of heart transplants in the United States, with the greatest growth in use for those not considered to be candidates for heart transplantation, previously referred to as destination therapy. This article will review the substantial progress that has taken place for both of these life-saving treatment options, as well as the future directions.
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Affiliation(s)
- Leslie Miller
- From the Division of Cardiovascular Medicine, Texas Heart Institute, Houston (L.M., H.L., O.H.F.)
| | - Emma Birks
- Division of Cardiology, University of Louisville, KY (E.B.)
| | - Maya Guglin
- Division of Cardiology, University of Kentucky, Lexington (M.G.)
| | - Harveen Lamba
- From the Division of Cardiovascular Medicine, Texas Heart Institute, Houston (L.M., H.L., O.H.F.)
| | - O H Frazier
- From the Division of Cardiovascular Medicine, Texas Heart Institute, Houston (L.M., H.L., O.H.F.)
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32
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Lee F, Nair V, Chih S. Cardiac allograft vasculopathy: Insights on pathogenesis and therapy. Clin Transplant 2020; 34:e13794. [PMID: 31991002 DOI: 10.1111/ctr.13794] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 01/14/2020] [Accepted: 01/23/2020] [Indexed: 12/21/2022]
Abstract
Cardiac allograft vasculopathy (CAV) is a unique accelerated form of coronary vascular disease affecting heart transplant recipients. This complication is a significant contributor to medium- to long-term post-transplant morbidity and mortality. There is a high prevalence of CAV with approximately one in three patients developing CAV by 5 years post-transplant. Morphologically, CAV is characterized by concentric coronary intimal hyperplasia in both the epicardial arteries and intramural microvasculature. Although several immune and non-immune factors have been identified, their precise pathogenic mechanisms, interactions, and relative importance in the development of CAV are not well defined. The advent of improved imaging surveillance modalities has resulted in earlier detection during the disease process. However, overall management of CAV remains challenging due to paucity of treatment. This review aims to discuss key concepts on the pathogenesis of CAV and current management strategies, focusing on the use of mammalian target of rapamycin inhibitors.
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Affiliation(s)
- Felicity Lee
- Heart Failure and Transplantation, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Vidhya Nair
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sharon Chih
- Heart Failure and Transplantation, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada
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33
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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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34
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Bellumkonda L, Patel J. Recent advances in the role of mammalian target of rapamycin inhibitors on cardiac allograft vasculopathy. Clin Transplant 2019; 34:e13769. [DOI: 10.1111/ctr.13769] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/02/2019] [Accepted: 12/05/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Lavanya Bellumkonda
- Division of Cardiology Department of Medicine Yale School of Medicine New Haven CT USA
| | - Jignesh Patel
- Cedars‐Sinai Medical Center Smidt Heart Institute Los Angeles CA USA
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35
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de Ferranti SD, Steinberger J, Ameduri R, Baker A, Gooding H, Kelly AS, Mietus-Snyder M, Mitsnefes MM, Peterson AL, St-Pierre J, Urbina EM, Zachariah JP, Zaidi AN. Cardiovascular Risk Reduction in High-Risk Pediatric Patients: A Scientific Statement From the American Heart Association. Circulation 2019; 139:e603-e634. [PMID: 30798614 DOI: 10.1161/cir.0000000000000618] [Citation(s) in RCA: 210] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This scientific statement presents considerations for clinical management regarding the assessment and risk reduction of select pediatric populations at high risk for premature cardiovascular disease, including acquired arteriosclerosis or atherosclerosis. For each topic, the evidence for accelerated acquired coronary artery disease and stroke in childhood and adolescence and the evidence for benefit of interventions in youth will be reviewed. Children and adolescents may be at higher risk for cardiovascular disease because of significant atherosclerotic or arteriosclerotic risk factors, high-risk conditions that promote atherosclerosis, or coronary artery or other cardiac or vascular abnormalities that make the individual more vulnerable to the adverse effects of traditional cardiovascular risk factors. Existing scientific statements and guidelines will be referenced when applicable, and suggestions for risk identification and reduction specific to each setting will be described. This statement is directed toward pediatric cardiologists, primary care providers, and subspecialists who provide clinical care for these young patients. The focus will be on management and justification for management, minimizing information on pathophysiology and epidemiology.
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36
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DeSa TB, Abbasi MA, Blaisdell JA, Lin K, Collins JD, Carr JC, Markl M. Semi-quantitative myocardial perfusion MRI in heart transplant recipients at rest: repeatability in healthy controls and assessment of cardiac allograft vasculopathy. Clin Imaging 2019; 61:62-68. [PMID: 31981959 DOI: 10.1016/j.clinimag.2019.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 11/25/2019] [Accepted: 12/16/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cardiac Allograft Vasculopathy (CAV) is a major cause of chronic cardiac allograft failure. Invasive coronary angiography (ICA) and intravascular ultrasound (IVUS) are the current diagnostic methods. Myocardial perfusion MRI has become a promising non-invasive method to evaluate myocardial ischemia, but has not been thoroughly validated in CAV. Our objective was to assess the repeatability of myocardial rest-perfusion MRI in healthy volunteers and its feasibility in detecting CAV in transplant patients (Tx). METHODS Twelve healthy volunteers and twenty transplant patients beyond the first year post- transplant underwent cardiac MRI at 1.5 T at rest including first-pass perfusion imaging in short axis (base, mid, apex) after injection of gadolinium. Volunteers underwent repeated cardiac MRI on different days (interval = 15.6 ± 2.4 days) to assess repeatability. Data analysis included semi-automatic contouring of endocardial and epicardial borders of the left ventricle (LV) and quantification of peak perfusion, time-to-peak (TTP) perfusion, and upslope of the perfusion curve. RESULTS Between scans and re-scans in healthy volunteers, peak signal intensity, slope, and TTP demonstrated moderate agreement (ICC = 0.53, 0.48, and 0.59, respectively; all, p < .001). Peak signal intensity, slope, and TTP were moderately variable with COV values of 23%, 42%, and 35%, respectively. Peak perfusion was significantly reduced in CAV positive (n = 9 Tx patients) compared to CAV negative (n = 11 Tx patients) groups (90.7 ± 27.0 vs 139.5 ± 30.2, p < .001). CONCLUSION Cardiac MRI is a moderately repeatable method for the semi-quantitative assessment of first-pass myocardial perfusion at rest. Semi-quantitative surrogate markers of LV perfusion could play a role in CAV detection.
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Affiliation(s)
- Travis B DeSa
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA.
| | - Muhannad A Abbasi
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA
| | - Julie A Blaisdell
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA
| | - Kai Lin
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA
| | - Jeremy D Collins
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA; Mayo Clinic, Department of Radiology, Rochester, MN, USA
| | - James C Carr
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA
| | - Michael Markl
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA; Northwestern University McCormick School of Engineering, Department of Biomedical Engineering, 2145 Sheridan Rd, Evanston, IL 60208, USA
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37
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Combined heart and kidney transplantation—Is there a protective effect against cardiac allograft vasculopathy using intravascular ultrasound? J Heart Lung Transplant 2019; 38:956-962. [DOI: 10.1016/j.healun.2019.06.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/14/2019] [Accepted: 06/16/2019] [Indexed: 11/20/2022] Open
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38
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Konerman MC, Lazarus JJ, Weinberg RL, Shah RV, Ghannam M, Hummel SL, Corbett JR, Ficaro EP, Aaronson KD, Colvin MM, Koelling TM, Murthy VL. Reduced Myocardial Flow Reserve by Positron Emission Tomography Predicts Cardiovascular Events After Cardiac Transplantation. Circ Heart Fail 2019; 11:e004473. [PMID: 29891737 DOI: 10.1161/circheartfailure.117.004473] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND We evaluated the diagnostic and prognostic value of quantification of myocardial flow reserve (MFR) with positron emission tomography (PET) in orthotopic heart transplant patients. METHODS AND RESULTS We retrospectively identified orthotopic heart transplant patients who underwent rubidium-82 cardiac PET imaging. The primary outcome was the composite of cardiovascular death, acute coronary syndrome, coronary revascularization, and heart failure hospitalization. Cox regression was used to evaluate the association of MFR with the primary outcome. The relationship of MFR and cardiac allograft vasculopathy severity in patients with angiography within 1 year of PET imaging was assessed using Spearman rank correlation and logistic regression. A total of 117 patients (median age, 60 years; 71% men) were identified. Twenty-one of 62 patients (34%) who underwent angiography before PET had cardiac allograft vasculopathy. The median time from orthotopic heart transplant to PET imaging was 6.4 years (median global MFR, 2.31). After a median of 1.4 years, 22 patients (19%) experienced the primary outcome. On an unadjusted basis, global MFR (hazard ratio, 0.22 per unit increase; 95% confidence interval, 0.09-0.50; P<0.001) and stress myocardial blood flow (hazard ratio, 0.48 per unit increase; 95% confidence interval, 0.29-0.79; P=0.004) were associated with the primary outcome. Decreased MFR independently predicted the primary outcome after adjustment for other variables. In 42 patients who underwent angiography within 12 months of PET, MFR and stress myocardial blood flow were associated with moderate-severe cardiac allograft vasculopathy (International Society of Heart and Lung Transplantation grade 2-3). CONCLUSIONS MFR assessed by cardiac rubidium-82 PET imaging is a predictor of cardiovascular events after orthotopic heart transplant and is associated with cardiac allograft vasculopathy severity.
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Affiliation(s)
- Matthew C Konerman
- Division of Cardiovascular Medicine, Department of Internal Medicine (M.C.K., J.J.L., R.L.W., M.G., S.L.H., J.R.C., K.D.A., M.M.C., T.M.K., V.L.M.)
| | - John J Lazarus
- Division of Cardiovascular Medicine, Department of Internal Medicine (M.C.K., J.J.L., R.L.W., M.G., S.L.H., J.R.C., K.D.A., M.M.C., T.M.K., V.L.M.)
| | - Richard L Weinberg
- Division of Cardiovascular Medicine, Department of Internal Medicine (M.C.K., J.J.L., R.L.W., M.G., S.L.H., J.R.C., K.D.A., M.M.C., T.M.K., V.L.M.)
| | - Ravi V Shah
- University of Michigan, Ann Arbor. Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (R.V.S.)
| | | | - Scott L Hummel
- Division of Cardiovascular Medicine, Department of Internal Medicine (M.C.K., J.J.L., R.L.W., M.G., S.L.H., J.R.C., K.D.A., M.M.C., T.M.K., V.L.M.)
| | - James R Corbett
- Division of Cardiovascular Medicine, Department of Internal Medicine (M.C.K., J.J.L., R.L.W., M.G., S.L.H., J.R.C., K.D.A., M.M.C., T.M.K., V.L.M.).,Division of Nuclear Medicine, Department of Radiology (J.R.C., E.P.F., V.L.M.)
| | - Edward P Ficaro
- Division of Cardiovascular Medicine, Department of Internal Medicine (M.C.K., J.J.L., R.L.W., M.G., S.L.H., J.R.C., K.D.A., M.M.C., T.M.K., V.L.M.).,Division of Nuclear Medicine, Department of Radiology (J.R.C., E.P.F., V.L.M.)
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine (M.C.K., J.J.L., R.L.W., M.G., S.L.H., J.R.C., K.D.A., M.M.C., T.M.K., V.L.M.)
| | - Monica M Colvin
- Division of Cardiovascular Medicine, Department of Internal Medicine (M.C.K., J.J.L., R.L.W., M.G., S.L.H., J.R.C., K.D.A., M.M.C., T.M.K., V.L.M.)
| | - Todd M Koelling
- Division of Cardiovascular Medicine, Department of Internal Medicine (M.C.K., J.J.L., R.L.W., M.G., S.L.H., J.R.C., K.D.A., M.M.C., T.M.K., V.L.M.)
| | - Venkatesh L Murthy
- Division of Cardiovascular Medicine, Department of Internal Medicine (M.C.K., J.J.L., R.L.W., M.G., S.L.H., J.R.C., K.D.A., M.M.C., T.M.K., V.L.M.).,Division of Nuclear Medicine, Department of Radiology (J.R.C., E.P.F., V.L.M.)
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39
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Arsanjani R, Khitri A, Hashemzadeh M, Movahed MR. Initial Intravascular Ultrasound Without a Routine Early Baseline Study in the Evaluation of Cardiac Transplant Vasculopathy has Prognostic Valve. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:1105-1109. [PMID: 30745023 DOI: 10.1016/j.carrev.2019.01.028] [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] [Received: 12/03/2018] [Revised: 01/10/2019] [Accepted: 01/22/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Abnormal minimal intimal thickening (MIT) on intravascular ultrasound (IVUS) defined as difference of ≥0.5 mm between baseline and one-year post-transplantation has been shown to have prognostic value. The goal of this retrospective cohort study was to evaluate whether abnormal MIT found on routine IVUS studies in cardiac transplant patients after 6 months without an early baseline study (modified MIT or MMIT), has any prognostic value. Furthermore, we evaluated the prognostic effect of serial IVUS performed beyond one year. METHODS A cohort of 149 cardiac transplant patients who underwent IVUS examination > 6 months post-transplant were evaluated retrospectively. Of these 149 patients, 109 patients underwent a subsequent IVUS study approximately 1 year following the initial study. MMIT values of ≥0.5 mm without an early baseline study were correlated with major adverse cardiac event (MACE). RESULTS The all-cause mortality was 4.7% (5/107) in patients with MMIT of <0.5 mm vs. 14.6% (6/41) in patients with MMIT of ≥0.5 mm [hazards ratio (HR): 3.2; 95% confidence interval (CI): 1.002-12.17; p = 0.039]. The overall MACE rate was 8.4% (9/107) in patients with MMIT of <0.5 mm vs. 24.4% (10/41) in patients with MMIT of ≥0.5 mm [HR: 6.7; 95% CI: 1.30-9.42; p = 0.009]. After adjusting for age, abnormal MMIT remained a significant independent predictor of MACE (HR: 3.93; CI 1.21-12.81; p = 0.023). CONCLUSIONS The presence of abnormal MMIT noted on IVUS performed after 6 months post-transplantation without a routine baseline IVUS carries important prognostic value.
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Affiliation(s)
- Reza Arsanjani
- Division of Cardiology, Mayo Clinic Arizona, Scottsdale, AZ, United States of America
| | - Avinash Khitri
- Division of Cardiology, The University of Arizona Sarver Heart Center, Tucson, AZ, United States of America
| | - Mehrnoosh Hashemzadeh
- Division of Cardiology, The University of Arizona Sarver Heart Center, Tucson, AZ, United States of America
| | - Mohammad Reza Movahed
- Division of Cardiology, The University of Arizona Sarver Heart Center, Tucson, AZ, United States of America; CareMore HealthCare, Tucson, AZ, United States of America.
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The change of immunosuppressive regimen from calcineurin inhibitors to mammalian target of rapamycin (mTOR) inhibitors and its effect on malignancy following heart transplantation. Int Immunopharmacol 2019; 69:150-158. [PMID: 30711744 DOI: 10.1016/j.intimp.2019.01.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/24/2019] [Accepted: 01/25/2019] [Indexed: 12/11/2022]
Abstract
Malignancy is a significant cause of mortality after organ transplantation. There is an increased rate of malignancy following heart transplantation (HTx) compared to the general population and other organ transplant recipients. Post-HTx patients with a history of malignancy are also at a higher risk of developing new malignancies or exacerbation of their existing malignancies. Mammalian target of Rapamycin inhibitors (mTORIs) are newly introduced immunosuppressive drugs with a unique mechanism of action. By changing the immunosuppressive regimen from classic drugs, especially calcineurin inhibitors (CNIs) to mTORIs, the rate of developing de novo malignancies and the relapse of former malignancies is significantly reduced. However, issues like allograft function, total surveillance of patients, and post-transplantation complications should be considered during the conversion of drug regimens utilizing CNIs to drug regimens employing mTORIs. We reviewed different post-heart transplant maintenance immunosuppressive regimens and their effect on post-HTx malignancies with a focus on mTORIs, compared safety against effectiveness, and gathered conclusions based on our review of the literature, which may lead clinicians to make a better evidence-based decision regarding post-HTx maintenance immunosuppressive drug regimens. Overall, CNI to mTORI conversion in post-HTx maintenance immunosuppressive drug regimens was associated with a reduced rate of developing malignancy in post-HTx patients. Furthermore, nephrotoxicity decreased significantly while using mTORIs in combination with lower doses of CNIs and the rejection rate was equivalent to CNI-only regimens. In conclusion, mTORI-based maintenance immunosuppressive drug regimens seem to be safe and beneficial when considering efficacy vs. adverse effects, and all-cause mortality rates are significantly lower in patients switched to mTORIs when compared to CNI recipients.
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Mociornita AG, Adamson MB, Tumiati LC, Ross HJ, Rao V, Delgado DH. Effects of everolimus and HLA-G on cellular proliferation and neutrophil adhesion in an in vitro model of cardiac allograft vasculopathy. Am J Transplant 2018; 18:3038-3044. [PMID: 29985558 DOI: 10.1111/ajt.15015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 07/03/2018] [Accepted: 07/04/2018] [Indexed: 01/25/2023]
Abstract
Human leukocyte antigen-G (HLA-G) expression is modulated by immunosuppressant use and is associated with lower incidence of graft rejection and cardiac allograft vasculopathy (CAV). We examined whether everolimus induces HLA-G expression and inhibits human coronary artery smooth muscle cell (HCASMC) proliferation, a critical event in CAV. Also, we examined whether TNFα-stimulated neutrophil adhesion is inhibited by HLA-G on human coronary artery endothelial cells (HCAECs). HLA-G expression in HCASMCs following everolimus treatment was determined by western-blot densitometric analysis. HCASMCs proliferation following incubation with recombinant HLA-G was determined by automated cell counter detecting 2-10 µm particles. Assessment of recombinant HLA-G on neutrophil adhesion to HCAECs in response to TNF-α induced-injury was determined by nonstatic adhesion assays. HLA-G expression was upregulated in HCASMCs following everolimus exposure (1000 ng/ml; P < .05). HLA-G (500, 1000 ng/ml; both P < .05) reduced HCASMC proliferation and inhibited TNFα-stimulated neutrophil adhesion to endothelial cells at all concentrations (0.1-1 ng/ml; all P < .001). Our study reveals novel regulation of HLA-G by everolimus, by demonstrating HLA-G upregulation and subsequent inhibition of HCASMC proliferation. HLA-G is a potent inhibitor of neutrophil adhesion to HCAECs. Findings support HLA-G's importance and potential use in heart transplantation for preventative therapy or as a marker to identify patients at high risk for developing CAV.
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Affiliation(s)
| | - Mitchell B Adamson
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
| | - Laura C Tumiati
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
| | - Heather J Ross
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, University Health Network, Toronto, Ontario, Canada
| | - Diego H Delgado
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
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Optimizing the Safety Profile of Everolimus by Delayed Initiation in De Novo Heart Transplant Recipients: Results of the Prospective Randomized Study EVERHEART. Transplantation 2018; 102:493-501. [PMID: 28930797 PMCID: PMC5828375 DOI: 10.1097/tp.0000000000001945] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although everolimus potentially improves long-term heart transplantation (HTx) outcomes, its early postoperative safety profile had raised concerns and needs optimization. METHODS This 6-month, open-label, multicenter randomized trial was designed to compare the cumulative incidence of a primary composite safety endpoint comprising wound healing delays, pericardial effusion, pleural effusion needing drainage, and renal insufficiency events (estimated glomerular filtration rate ≤30/mL/min per 1.73 m) in de novo HTx recipients receiving immediate everolimus (EVR-I) (≤144 hours post-HTx) or delayed everolimus (EVR-D) (4-6 weeks post-HTx with mycophenolate mofetil as a bridge) with reduced-dose cyclosporine A. Cumulative incidence of biopsy-proven rejection ≥ 2R, rejection with hemodynamic compromise, graft loss, or death was the secondary composite efficacy endpoint. RESULTS Overall, 181 patients were randomized to the EVR-I (n = 89) or EVR-D (n = 92) arms. Incidence of primary safety endpoint was higher for EVR-I than EVR-D arm (44.9% vs 32.6%; P = 0.191), mainly driven by a higher rate of pericardial effusion (33.7% vs 19.6%; P = 0.04); wound healing delays, acute renal insufficiency events, and pleural effusion occurred at similar frequencies in the study arms. Efficacy failure was not significantly different in EVR-I arm versus EVR-D arm (37.1% vs 28.3%; P = 0.191). Three patients in the EVR-I arm and 1 in the EVR-D arm died. Incidence of clinically significant adverse events leading to discontinuation was higher in EVR-I arm versus EVR-D arm (P = 0.02). CONCLUSIONS Compared with immediate initiation, delayed everolimus initiation appeared to provide a clinically relevant early safety benefit in de novo HTx recipients, without compromising efficacy.
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Sen A, Callisen H, Libricz S, Patel B. Complications of Solid Organ Transplantation: Cardiovascular, Neurologic, Renal, and Gastrointestinal. Crit Care Clin 2018; 35:169-186. [PMID: 30447778 DOI: 10.1016/j.ccc.2018.08.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Despite improvements in overall graft function and patient survival rates after solid organ transplantation, complications can lead to significant morbidity and mortality. Cardiovascular complications include heart failure, arrhythmias leading to sudden death, hypertension, left ventricular hypertrophy, and allograft vasculopathy in heart transplantation. Neurologic complications include stroke, posterior reversible encephalopathy syndrome, infections, neuromuscular disease, seizure disorders, and neoplastic disease. Acute kidney injury occurs from immunosuppression with calcineurin inhibitors or as a result of graft failure after kidney transplantation. Gastrointestinal complications include infections, malignancy, mucosal ulceration, perforation, biliary tract disease, pancreatitis, and diverticular disease. Immunosuppression can predispose to infections and malignancy.
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Affiliation(s)
- Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.
| | - Hannelisa Callisen
- Department of Critical Care Medicine, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Stacy Libricz
- Department of Critical Care Medicine, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Bhavesh Patel
- Department of Critical Care Medicine, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
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Bhagra SK, Pettit S, Parameshwar J. Cardiac transplantation: indications, eligibility and current outcomes. Heart 2018; 105:252-260. [DOI: 10.1136/heartjnl-2018-313103] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Emerging Role of mTOR Signaling-Related miRNAs in Cardiovascular Diseases. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2018; 2018:6141902. [PMID: 30305865 PMCID: PMC6165581 DOI: 10.1155/2018/6141902] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 07/04/2018] [Indexed: 12/21/2022]
Abstract
Mechanistic/mammalian target of rapamycin (mTOR), an atypical serine/threonine kinase of the phosphoinositide 3-kinase- (PI3K-) related kinase family, elicits a vital role in diverse cellular processes, including cellular growth, proliferation, survival, protein synthesis, autophagy, and metabolism. In the cardiovascular system, the mTOR signaling pathway integrates both intracellular and extracellular signals and serves as a central regulator of both physiological and pathological processes. MicroRNAs (miRs), a class of short noncoding RNA, are an emerging intricate posttranscriptional modulator of critical gene expression for the development and maintenance of homeostasis across a wide array of tissues, including the cardiovascular system. Over the last decade, numerous studies have revealed an interplay between miRNAs and the mTOR signaling circuit in the different cardiovascular pathophysiology, like myocardial infarction, hypertrophy, fibrosis, heart failure, arrhythmia, inflammation, and atherosclerosis. In this review, we provide a comprehensive state of the current knowledge regarding the mechanisms of interactions between the mTOR signaling pathway and miRs. We have also highlighted the latest advances on mTOR-targeted therapy in clinical trials and the new perspective therapeutic strategies with mTOR-targeting miRs in cardiovascular diseases.
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Langstraat M, Musters KJS, Manintveld O, Masetti M, Potena L. Coronary artery disease in heart transplantation: new concepts for an old disease. Transpl Int 2018; 31:787-827. [DOI: 10.1111/tri.13141] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
| | | | | | - Marco Masetti
- Heart and Lung Transplant Program; Bologna University Hospital; Bologna Italy
| | - Luciano Potena
- Heart and Lung Transplant Program; Bologna University Hospital; Bologna Italy
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Lazarte J, Adamson MB, Tumiati LC, Delgado DH. 10-Year Experience with HLA-G in Heart Transplantation. Hum Immunol 2018; 79:587-593. [PMID: 29859206 DOI: 10.1016/j.humimm.2018.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 05/19/2018] [Accepted: 05/21/2018] [Indexed: 11/19/2022]
Abstract
The Human Leukocyte Antigen-G (HLA-G) is a MHC-class Ib molecule with robust immunomodulatory properties; in transplant, it inhibits cytotoxic activity of immune cells and thus has a pivotal role in protecting the allograft from immune attack. The present review details a 10-year experience investigating the influence of HLA-G on heart transplantation, allograft rejection and cardiac allograft vasculopathy development. Exploration of HLA-G in transplantation began with the initial findings of its increased expression in allograft hearts. Since then, HLA-G has been recognized as an important factor in transplant immunology. We discuss inducers of HLA-G expression, and the importance of HLA-G as a potential biomarker in allograft rejection and heart failure. We also highlight the importance of polymorphisms and how they may influence both HLA-G expression and clinical outcomes. There remains much to be done in this field, however we hope that findings from our group and other groups will ignite interest and facilitate further expansion of HLA-G research in transplantation.
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Affiliation(s)
- Julieta Lazarte
- Departments of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada.
| | - Mitchell B Adamson
- Department of Medicine, Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Laura C Tumiati
- Department of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Diego H Delgado
- Department of Cardiology, Hear Failure and Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Kim IC, Youn JC, Kobashigawa JA. The Past, Present and Future of Heart Transplantation. Korean Circ J 2018; 48:565-590. [PMID: 29968430 PMCID: PMC6031715 DOI: 10.4070/kcj.2018.0189] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 06/18/2018] [Indexed: 01/04/2023] Open
Abstract
Heart transplantation (HTx) has become standard treatment for selected patients with end-stage heart failure. Improvements in immunosuppressant, donor procurement, surgical techniques, and post-HTx care have resulted in a substantial decrease in acute allograft rejection, which had previously significantly limited survival of HTx recipients. However, limitations to long-term allograft survival exist, including rejection, infection, coronary allograft vasculopathy, and malignancy. Careful balance of immunosuppressive therapy and vigilant surveillance for complications can further improve long-term outcomes of HTx recipients.
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Affiliation(s)
- In Cheol Kim
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Jong Chan Youn
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea.
| | - Jon A Kobashigawa
- Division of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA.
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