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Martini L, Mandoli GE, Pastore MC, Pagliaro A, Bernazzali S, Maccherini M, Henein M, Cameli M. Heart transplantation and biomarkers: a review about their usefulness in clinical practice. Front Cardiovasc Med 2024; 11:1336011. [PMID: 38327491 PMCID: PMC10847311 DOI: 10.3389/fcvm.2024.1336011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/12/2024] [Indexed: 02/09/2024] Open
Abstract
Advanced heart failure (AdvHF) can only be treated definitively by heart transplantation (HTx), yet problems such right ventricle dysfunction (RVD), rejection, cardiac allograft vasculopathy (CAV), and primary graft dysfunction (PGD) are linked to a poor prognosis. As a result, numerous biomarkers have been investigated in an effort to identify and prevent certain diseases sooner. We looked at both established biomarkers, such as NT-proBNP, hs-troponins, and pro-inflammatory cytokines, and newer ones, such as extracellular vesicles (EVs), donor specific antibodies (DSA), gene expression profile (GEP), donor-derived cell free DNA (dd-cfDNA), microRNA (miRNA), and soluble suppression of tumorigenicity 2 (sST2). These biomarkers are typically linked to complications from HTX. We also highlight the relationships between each biomarker and one or more problems, as well as their applicability in routine clinical practice.
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Affiliation(s)
- L. Martini
- Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - G. E. Mandoli
- Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - M. C. Pastore
- Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - A. Pagliaro
- Cardio-Thoracic-Vascular Department, Siena University Hospital, Siena, Italy
| | - S. Bernazzali
- Cardio-Thoracic-Vascular Department, Siena University Hospital, Siena, Italy
| | - M. Maccherini
- Cardio-Thoracic-Vascular Department, Siena University Hospital, Siena, Italy
| | - M. Henein
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - M. Cameli
- Department of Medical Biotechnology, University of Siena, Siena, Italy
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Liu Z, Perry LA, Penny-Dimri JC, Handscombe M, Overmars I, Plummer M, Segal R, Smith JA. Elevated Cardiac Troponin to Detect Acute Cellular Rejection After Cardiac Transplantation: A Systematic Review and Meta-Analysis. TRANSPLANT INTERNATIONAL : OFFICIAL JOURNAL OF THE EUROPEAN SOCIETY FOR ORGAN TRANSPLANTATION 2022; 35:10362. [PMID: 35755856 PMCID: PMC9215116 DOI: 10.3389/ti.2022.10362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 05/17/2022] [Indexed: 11/13/2022]
Abstract
Cardiac troponin is well known as a highly specific marker of cardiomyocyte damage, and has significant diagnostic accuracy in many cardiac conditions. However, the value of elevated recipient troponin in diagnosing adverse outcomes in heart transplant recipients is uncertain. We searched MEDLINE (Ovid), Embase (Ovid), and the Cochrane Library from inception until December 2020. We generated summary sensitivity, specificity, and Bayesian areas under the curve (BAUC) using bivariate Bayesian modelling, and standardised mean differences (SMDs) to quantify the diagnostic relationship of recipient troponin and adverse outcomes following cardiac transplant. We included 27 studies with 1,684 cardiac transplant recipients. Patients with acute rejection had a statistically significant late elevation in standardised troponin measurements taken at least 1 month postoperatively (SMD 0.98, 95% CI 0.33–1.64). However, pooled diagnostic accuracy was poor (sensitivity 0.414, 95% CrI 0.174–0.696; specificity 0.785, 95% CrI 0.567–0.912; BAUC 0.607, 95% CrI 0.469–0.723). In summary, late troponin elevation in heart transplant recipients is associated with acute cellular rejection in adults, but its stand-alone diagnostic accuracy is poor. Further research is needed to assess its performance in predictive modelling of adverse outcomes following cardiac transplant. Systematic Review Registration: identifier CRD42021227861
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Affiliation(s)
- Zhengyang Liu
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Luke A Perry
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Jahan C Penny-Dimri
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Michael Handscombe
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Isabella Overmars
- Infection and Immunity Theme, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Mark Plummer
- Department of Intensive Care Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia.,Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Reny Segal
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, VIC, Australia.,Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Julian A Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
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ACCF 2012 expert consensus document on practical clinical considerations in the interpretation of troponin elevations: a report of the American College of Cardiology Foundation task force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2012; 60:2427-63. [PMID: 23154053 DOI: 10.1016/j.jacc.2012.08.969] [Citation(s) in RCA: 263] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Emergency Department Presentation of Heart Transplant Recipients with Acute Heart Failure. Heart Fail Clin 2009; 5:129-43, viii. [DOI: 10.1016/j.hfc.2008.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Dengler TJ, Gleissner CA, Klingenberg R, Sack FU, Schnabel PA, Katus HA. Biomarkers After Heart Transplantation: Nongenomic. Heart Fail Clin 2007; 3:69-81. [DOI: 10.1016/j.hfc.2007.02.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Mullen JC, Bentley MJ, Scherr KD, Chorney SG, Burton NI, Tymchak WJ, Koshal A, Modry DL. Troponin T and I are not reliable markers of cardiac transplant rejection. Eur J Cardiothorac Surg 2002; 22:233-7. [PMID: 12142191 DOI: 10.1016/s1010-7940(02)00293-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE Heart transplant recipients undergo a number of invasive endomyocardial biopsies to screen for rejection. Serum assays of troponin T and/or I may provide a less invasive alternative. The purpose of this study was to evaluate troponin T and I as markers of cardiac transplant rejection. METHODS We conducted a prospective analysis comparing troponin T and I levels to biopsy results in heart transplant recipients. Plasma was assayed for troponin T and I preoperatively, on the first 3 postoperative days, and with each subsequent biopsy. RESULTS Twenty-nine patients entered the study. A total of 173 biopsies were performed at a mean follow-up of 129+/-9 days (range: 12-564 days). There were two rejection episodes (> or = grade 3), one in each of two patients. There were no significant relationships between troponin T or I and biopsy-proven rejection (> or = grade 3; P=0.59 and 0.54, respectively). There were also no correlations between troponin T or I levels and biopsy grade (P=0.40 and 0.92, respectively). Troponin T and I levels peaked on postoperative day 1 and fell to baseline over long-term follow-up with no peak in serum markers associated with rejection episodes. Donor ischemic time was significantly correlated to troponin T on postoperative days 1-3 (r=0.58, P=0.005; r=0.61, P=0.004; and r=0.61, P=0.003, respectively). CONCLUSIONS Troponin T and I are not useful indicators of cardiac rejection, but do correlate with donor heart ischemic injury.
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Affiliation(s)
- J C Mullen
- Division of Cardiac Surgery, The University of Alberta Hospital, 2D2.18 W.C. Mackenzie Health Sciences Centre, 8440-112 Street, Edmonton, Alta T6G 2B7, Canada.
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Abstract
A major impediment for the long-term success of heart transplantation is the development of transplant coronary artery disease (CAD). Several risk factors for the development of transplant CAD are associated with the transformation of a normal thromboresistant microvasculature into a prothrombogenic microvasculature. Prothrombogenicity is characterized by loss of anticoagulation (i.e. loss of antithrombin), loss of fibrinolytic activity (i.e., loss of tissue plasminogen activator) and presence of endothelial activation (i.e. upregulation of endothelial intercellular adhesion molecule-1 and major histocompatibility class II antigen human leukocyte antigen-DR) in the arterial allograft microvasculature. Microvascular prothrombogenicity during the first trimester after transplantation is directly associated with subsequent development of transplant CAD. Although the mechanisms responsible for the loss of thromboresistant endothelium are unclear, the fact that changes in the anticoagulant, fibrinolytic, and activational status of endothelial cells may occur early after transplantation suggests a peritransplant phenomenon as an initiating event. Reducing prothrombogenicity of the cardiac microvasculature early after transplantation could slow the development of transplant CAD and significantly improve allograft survival.
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Affiliation(s)
- Carlos A Labarrere
- Methodist Research Institute at Clarian Health, Indianapolis, IN 46202, USA.
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Chance JJ, Segal JB, Wallerson G, Kasper E, Hruban RH, Kickler TS, Chan DW. Cardiac troponin T and C-reactive protein as markers of acute cardiac allograft rejection. Clin Chim Acta 2001; 312:31-9. [PMID: 11580907 DOI: 10.1016/s0009-8981(01)00590-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Due to myocyte damage and an associated inflammatory response, it is possible that cardiac troponin T and C-reactive protein (CRP) concentrations may correlate with the histologic grade of rejection in endomyocardial biopsy samples obtained from patients who have received a heart transplant. In this study, 704 blood samples were obtained from 145 different heart transplant recipients just prior to endomyocardial biopsy. Plasma specimens were assayed for troponin T and CRP concentration and the results compared with the assigned International Society of Heart and Lung Transplantation (ISHLT) histologic grade. Rejection was defined as an ISHLT grade of 3A or higher. The negative predictive values were near 80% in all cases, and a statistically significant increase in median troponin T concentration was observed across ISHLT grades. After the first month posttransplantation, the specificity of the troponin T test (cutoff 0.1 ng/ml) was 95% and increased to 98% when false positives seen in renal disease patients were excluded. Both tests demonstrated poor sensitivity and positive predictive value for rejection. Neither CRP nor troponin T had sufficient sensitivity to serve as an alternative to endomyocardial biopsy in the diagnosis of acute cardiac allograft rejection. However, the troponin T test had a high specificity, especially when patients with renal insufficiency were excluded, and could serve as an adjunct test in this setting. When combined with a normal serum creatinine, a troponin T > or =0.1 ng/ml prior to endomyocardial biopsy correlated with graft rejection in almost all cases, making biopsy unnecessary.
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Affiliation(s)
- J J Chance
- Department of Pathology, Johns Hopkins Hospital, 600 N. Wolfe Street/Meyer B-125, Baltimore, MD 21287-7065, USA
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Potapov EV, Ivanitskaia EA, Loebe M, Möckel M, Müller C, Sodian R, Meyer R, Hetzer R. Value of cardiac troponin I and T for selection of heart donors and as predictors of early graft failure. Transplantation 2001; 71:1394-400. [PMID: 11391225 DOI: 10.1097/00007890-200105270-00007] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiac troponin I and T (cTnI and cTnT) are sensitive and specific markers of myocardial damage. We evaluated them for the selection of heart donors and as predictors of early graft failure after heart transplantation. METHODS cTnI, cTnT, myoglobin, and creatine kinase (CK) levels and its isoenzyme MB (CKMB) activity and mass were measured in serum samples immediately before opening the pericardium from 126 consecutive brain-dead multi-organ donors over 10 years of age inspected by our harvesting team. Donors with serum creatinine >2.0 mg/dL (n=6) were excluded from the analysis. Donors for high-urgency status recipients (n=2) were also excluded. The remaining donors were retrospectively divided into three groups: group I (n=68), grafts with good function; group II (n=11), grafts with impaired function; and group III (n=39), grafts not accepted for transplantation. RESULTS No differences in donor and recipient characteristics were found among the groups. The mean values of cTnI (0.36+/-0.88 microg/L, 4.45+/-3.28 microg/L, and 3.02+/-7.88 micog/L, respectively) and cTnT (0.016+/-0.029 microg/L, 0.134+/-0.114 microg/L, and 0.123+/-0.245 microg/L, respectively) were lower in group I when compared with groups II or III (cTnI: P<0.0001, P=0.018; cTnT: P<0.0001, P=0.012). The cTnI value was higher in group II compared with group III (P=0.023). The cTnT values were similar in groups II and III. A cTnI value >1.6 microg/L as a predictor of early graft failure had a specificity of 94%, and a cTnT value of >0.1 microg/L had a specificity of 99%. The odds ratio for the development of acute graft failure after heart transplantation was 42.7 for donors with cTnI >1.6 microg/L and 56.9 for donors with cTnT >0.1 microg/L. No differences of myoglobin, CKMB activity, or CKMB/CK ratio were found among the groups. CONCLUSIONS Significantly higher cTnI and cTnT values were found in peripheral blood at the time of explantation in donors of hearts with subsequently impaired graft function and in not accepted donors. cTnI and cTnT are useful as additional parameters for heart donor selection.
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Affiliation(s)
- E V Potapov
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Germany.
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Labarrere CA, Nelson DR, Park JW. Pathologic markers of allograft arteriopathy: insight into the pathophysiology of cardiac allograft chronic rejection. Curr Opin Cardiol 2001; 16:110-7. [PMID: 11224642 DOI: 10.1097/00001573-200103000-00006] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Transplant-associated coronary artery disease (CAD) is the principal limiting factor for the long-term survival of heart transplant patients. This review discusses early risk factors for the subsequent development of transplant-associated CAD. Early risk factors associated with a prothrombogenic microvasculature, such as deposition of microvascular fibrin, depletion of vascular tissue plasminogen activator, presence of endothelial activation of the allograft arterial tree, and loss of vascular antithrombin, as well as changes in circulation (ie, detectable serum cardiac troponin I and elevated serum soluble intercellular adhesion molecule-1 levels) are presented and discussed. New therapies that could improve the status of the allograft microvasculature and may prevent or mitigate the development of transplant-associated CAD are considered.
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Affiliation(s)
- C A Labarrere
- Methodist Research Institute, Clarian Health Partners, (Methodist, Indiana University, Riley Hospitals), 1701 N. Senate Blvd., Indianapolis, IN 46202, USA.
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Hökl J, Cerný J, Nĕmec P, Studeník P, Spinarová L, Malík P. Serum troponin T in the early posttransplant period and long-term graft function in heart recipients. Transplant Proc 2001; 33:2018-9. [PMID: 11267608 DOI: 10.1016/s0041-1345(00)02773-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- J Hökl
- Centre of Cardiovascular and Transplant Surgery, Brno, Czech Republic
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Torry RJ, Bai L, Miller SJ, Labarrere CA, Nelson D, Torry DS. Increased vascular endothelial growth factor expression in human hearts with microvascular fibrin. J Mol Cell Cardiol 2001; 33:175-84. [PMID: 11133233 DOI: 10.1006/jmcc.2000.1292] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We have shown that microvascular changes that promote fibrin deposition in human cardiac allografts adversely affect clinical outcome. However, some allografts exhibit phenotypic changes in capillaries following the deposition of fibrin, which subsequently provide a significant survival advantage. The mechanism(s) involved in these capillary changes is(are) unknown. Similarly, although we have shown a significant temporal relationship between microvascular fibrin deposition and vascular endothelial growth factor (VEGF) immunoreactivity in cardiac allografts, the cellular source and relative changes in VEGF gene expression under these conditions are not known. Using immunocytochemical techniques, biopsies devoid of fibrin deposition lacked detectable VEGF immunoreactivity, whereas biopsies with fibrin deposition showed VEGF immunoreactivity in cardiocytes, interstitium, and some microvessels. By in situ hybridization, biopsies without microvascular fibrin deposition showed faint VEGF hybridization signals confined primarily to cardiocytes. In biopsies with fibrin deposition, strong VEGF hybridization signals were detected in cardiocytes, arteriolar smooth muscle cells were occasionally labeled, and endothelial cells were rarely labeled. By quantitative RT-PCR, biopsies with fibrin deposition (n=5) relatively expressed approximately three-fold more VEGF mRNA than biopsies without fibrin deposition (n=5 P=0.02). Serum VEGF titers also were greater (P=0.01) in recipients with fibrin deposition (372.9+/-66.7 pg/ml n=18) compared to recipients without fibrin deposition (172.1+/-25.0 pg/ml n=16). Collectively, these results support the hypothesis that increased myocyte-derived VEGF production following microvascular fibrin deposition in transplanted human hearts may act in a paracrine manner to promote activational and phenotypic changes in capillaries that provide a survival advantage for the allografts.
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Affiliation(s)
- R J Torry
- College of Pharmacy and Health Sciences, Drake University, Des Moines, IA 50311, USA.
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Labarrere CA. Anticoagulation factors as predictors of transplant-associated coronary artery disease. J Heart Lung Transplant 2000; 19:623-33. [PMID: 10930810 DOI: 10.1016/s1053-2498(00)00112-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- C A Labarrere
- Methodist Research Institute, Clarian Health (Methodist, Indiana University, Riley Hospitals), Indianapolis, Indiana 46202, USA.
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Faulk WP, Rose M, Meroni PL, Del Papa N, Torry RJ, Labarrere CA, Busing K, Crisp SJ, Dunn MJ, Nelson DR. Antibodies to endothelial cells identify myocardial damage and predict development of coronary artery disease in patients with transplanted hearts. Hum Immunol 1999; 60:826-32. [PMID: 10527389 DOI: 10.1016/s0198-8859(99)00056-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Transplant-induced coronary artery disease is a leading cause of graft failure in cardiac allograft recipients after the first year of transplantation, but there presently is no test to identify patients at high risk for developing the disease. Our research is focused on development of a predictive test to identify patients at high risk of developing the disease. METHODS Sixty-eight cardiac allograft recipients transplanted and followed at Methodist Hospital between 1982 and 1996 were studied. Serial annual angiograms were used to diagnose coronary artery disease, and serial endomyocardial biopsies were used to detect cellular infiltrates and microvascular disease. Biopsy-matched serum samples were used for cardiac troponin-T determinations as measures of myocardial damage, and serum antibodies to endothelial cells were determined by using flow cytometry, enzyme-linked immunosorbent assay and immunoblotting techniques. The endothelial antibody data were evaluated statistically for associations with angiographic changes, biopsy findings and biochemical evidence of myocardial damage. FINDINGS Antibodies to endothelial cells were identified by all three techniques, and significant associations were found for the amount of antibody identified by Western immunoblotting with histological rejection grades in biopsies, which were confirmed immunocytochemically as macrophages (p<0.01) and T lymphocytes (P = 0.03). These antibodies also associated significantly with vascular antithrombin depletion (p = 0.02), biochemical evidence of myocardial damage (p = 0.005) and subsequent development of coronary artery disease (p = 0.03). INTERPRETATION The significant association of anti-endothelial antibodies with cellular infiltrates, depletion of vascular antithrombin and myocardial damage suggests a role for antibody in the development of transplant-induced arteriopathy. The significant association of antiendothelial antibodies with the future development of coronary artery disease further suggests that assessment of these antibodies may provide a non-invasive test to predict the development of transplant-induced coronary artery disease.
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Affiliation(s)
- W P Faulk
- Division of Experimental Pathology, Center for Reproduction and Transplantation Immunology, Methodist Hospital, Indianapolis, IN, USA
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Abstract
The development of transplant coronary artery disease (CAD) is directly associated with outcome in cardiac transplantation. The relationship between microvascular fibrin deposition early after transplantation and subsequent development of transplant CAD is discussed in this article. In this article the presence of microvascular fibrin and its association with other prothrombogenic changes within the cardiac microvasculature, such as loss of vascular antithrombin, depletion of arteriolar tissue plasminogen activator, and presence of arterial and arteriolar endothelium activation, as well as changes in circulation associated with prothrombogenic changes that have predictive value for subsequent transplant outcome are presented and discussed. Novel therapeutic approaches that may prevent the development of transplant CAD and consequently affect outcome are considered.
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Affiliation(s)
- C A Labarrere
- Methodist Research Institute, Clarian Health (Methodist, Indiana University, Riley Hospitals), Indianapolis 46202, USA
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