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Lin-Wang HT, Cipullo R, Dias França JI, Finger MA, Rossi Neto JM, Correia EDB, Dinkhuysen JJ, Hirata MH. Intragraft vasculitis and gene expression analysis: Association with acute rejection and prediction of mortality in long-term heart transplantation. Clin Transplant 2018; 32:e13373. [PMID: 30080295 DOI: 10.1111/ctr.13373] [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: 04/11/2018] [Revised: 07/31/2018] [Accepted: 08/01/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Vasculitis entails heterogeneous origins; it starts with an inflammatory process that leads to small vessels' necrosis, hemorrhage, and ischemic lesion, and may further result in occlusion of the vascular lumen. Vasculitis' contribution to allograft rejection is still unclear. This study aims to investigate the incidence of vasculitis in the early stages of heart transplantation as well as to assess the intragraft genes' expression associated with vascular function and subsequently to verify the way in which it affects the outcome of the allograft. METHODS In this retrospective study, 300 archive paraffin-embedded endomyocardial biopsies from 63 heart allograft recipients were assessed. Cellular rejection and vasculitis were diagnosed through histological analysis, and antibody-mediated rejection was performed with immunohistochemical C4d staining. The transcripts of ICAM, VCAM, VEGF, CCL2, IFNG, TGFB, TNF, ADIPOR1, and ADIPOR2 genes were examined through quantitative polymerase chain reaction using B2M for normalization. RESULTS We observed a higher prevalence of severe vasculitis in the early period of post-transplant, and recovery was observed to take place around 1 year post-transplant. Additionally, vasculitis was found to be directly associated with acute cellular rejection and antibody-mediated rejection. The intense C4d capillary positivity predicts higher long-term cardiovascular disease mortality. In comparison with the vasculitis-free group, the group with severe vasculitis displayed reduced left ventricular ejection fraction and an upregulation of VCAM and IFNG associated with the downregulation of VEGF, ADIPOR1, and ADIPOR2. CONCLUSION The vasculitis associated with the presence of C4d and the change in intragraft gene expression profile may contribute to poor allograft outcomes.
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Affiliation(s)
- Hui Tzu Lin-Wang
- Laboratory of Molecular Investigation in Cardiology, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | - Reginaldo Cipullo
- Department of Heart Transplantation, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | - João Italo Dias França
- Statistic and Epidemiology Laboratory, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | - Marco Aurelio Finger
- Department of Heart Transplantation, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | - Joao Manoel Rossi Neto
- Department of Heart Transplantation, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | | | | | - Mário Hiroyuki Hirata
- Laboratory of Molecular Investigation in Cardiology, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil.,School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
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Comparison Between Cardiac Allograft Vasculopathy and Native Coronary Atherosclerosis by Optical Coherence Tomography. Am J Cardiol 2016; 117:1361-8. [PMID: 26920081 DOI: 10.1016/j.amjcard.2016.01.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 01/20/2016] [Accepted: 01/20/2016] [Indexed: 12/20/2022]
Abstract
We sought to explore differences in distribution and morphology of coronary lesions comparing cardiac allograft vasculopathy and native coronary atherosclerosis (NCA) using intravascular imaging with optical coherence tomography (OCT). At the time of routine surveillance angiography, 17 heart transplant (HT) recipients with a history of high-grade cellular rejection (HGR) and 43 HT recipients with none/mild (low)-grade rejection underwent OCT imaging of the left anterior descending and were compared to 60 patients with NCA without HT. Compared with patients with NCA, patients with HGR had similar intima areas but smaller external elastic lamina areas (7.9 mm(2) [6.3, 11.2] versus 6.6 mm(2) [4.8, 7.5], p = 0.02) resulting in smaller lumen areas (4.5 mm(2) [3.4, 6.6] versus 3.3 mm(2) [2.8, 4.7], p = 0.04) in distal segments and smaller lumen diameters in side branches (1.28 mm [1.19, 1.37] versus 1.09 mm [0.94, 1.24], p = 0.04). Compared with patients with NCA, lesions in patients with HT were more homogeneous, involving the entire coronary vascular tree. Patients with HGR had a higher prevalence of macrophages involving ≥1 quadrant in all 3 segments compared with patients with NCA. The number of microvessels was greater in patients with both HGR and LGR HT versus NCA. In conclusion, distinct findings in the distribution and morphology of coronary lesions between HT recipients and patients with NCA are evident by OCT imaging, suggesting that OCT might be useful to help differentiate cardiac allograft vasculopathy from NCA in vivo.
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Crudele GDL, Amadasi A, Marasciuolo L, Rancati A, Gentile G, Zoja R. A case report of lethal post-viral lymphocytic myocarditis with exclusive location in the right ventricle. Leg Med (Tokyo) 2016; 19:1-4. [PMID: 26980245 DOI: 10.1016/j.legalmed.2016.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 01/04/2016] [Accepted: 01/12/2016] [Indexed: 11/29/2022]
Abstract
The inflammatory involvement of vital organs may represent a dangerous and life-threatening situation: in particular, the inflammation of the myocardial tissue of the heart may lead to severe consequences since the clinical history of the disease may be completely asymptomatic, any clinical sign may be lacking, thus preventing correct diagnosis and treatment. This may occur even in the case of myocarditis and may lead to unexpected death whose cause can be assessable only by means of a thorough histopathological examination. The article reports the case of 61-year old female who developed a flu-like syndrome with very few symptoms, followed by sudden death in three weeks. The autopsy and following histopathological investigations identified the cause of death in a post-viral lymphocytic myocarditis, probably related to the previous infectious disease, and alternative causes (as arrhythmic ventricular dysplasia, vasculitis, sarcoidosis and giant cell myocarditis) were excluded. The exclusive location in the right ventricle was a peculiar finding. The case highlights the importance of the myocardium of the right ventricle, a tissue which is often less considered even in histopathological surveys. The exclusive location of myocarditis in the right ventricle is a rare event but in this case fully responsible for death.
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Affiliation(s)
- Graziano Domenico Luigi Crudele
- Sezione di Medicina Legale e delle Assicurazioni, Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Luigi Mangiagalli 37, Milano, Italy
| | - Alberto Amadasi
- Sezione di Medicina Legale e delle Assicurazioni, Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Luigi Mangiagalli 37, Milano, Italy.
| | - Laura Marasciuolo
- Sezione di Medicina Legale e delle Assicurazioni, Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Luigi Mangiagalli 37, Milano, Italy
| | - Alessandra Rancati
- Sezione di Medicina Legale e delle Assicurazioni, Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Luigi Mangiagalli 37, Milano, Italy
| | - Guendalina Gentile
- Sezione di Medicina Legale e delle Assicurazioni, Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Luigi Mangiagalli 37, Milano, Italy
| | - Riccardo Zoja
- Sezione di Medicina Legale e delle Assicurazioni, Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Luigi Mangiagalli 37, Milano, Italy
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Egan C, Margey R, O'Keane C, Egan J, Fabre A. Sudden death late post-cardiac transplantation as a consequence of cardiac allograft vasculitis. J Heart Lung Transplant 2010; 29:1438-9. [PMID: 20851641 DOI: 10.1016/j.healun.2010.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Revised: 07/31/2010] [Accepted: 08/01/2010] [Indexed: 12/01/2022] Open
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Perens G, Li F, Meier S, Kaur R, Alejos JC, Fishbein M. Clinico-pathologic findings in end-stage pediatric heart transplant grafts. Pediatr Transplant 2009; 13:887-91. [PMID: 19017288 DOI: 10.1111/j.1399-3046.2008.01087.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The pathologic patterns existing in end-stage pediatric heart transplant grafts may help explain the symptoms and changes seen by echocardiography and angiography in these children. Retrospective chart review and pathologic study of explanted heart grafts was performed on 12 patients that had undergone 14 heart re-transplantations. Clinical status, echocardiographic and catheterization data at the time of transplantation were correlated to the pathologic findings. At re-OHT, eight were inpatients with heart failure symptoms and/or inotropic support requirements. Echocardiograms were abnormal in all prior to re-OHT with significant diastolic dysfunction, but LVEF >40% in all but one. There was significant epicardial fibrosis in all grafts, and all had severe CAV of epicardial arteries. However, intramyocardial coronary disease was mild in nine (64%) grafts. Moderate or severe interstitial fibrosis occurred in only three grafts, and in a perivascular distribution in eight. End-stage pediatric heart allografts have severe epicardial CAV and epicardial fibrosis, with relative sparing of the myocardium. Epicardial disease with sparing of the myocardium may explain the restrictive hemodynamics and relatively preserved systolic function present in these grafts at the time of re-OHT.
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Affiliation(s)
- Gregory Perens
- Department of Pediatrics, Mattel Children's Hospital at UCLA, Los Angeles, CA 90095, USA.
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Inflammatory burden of cardiac allograft coronary atherosclerotic plaque is associated with early recurrent cellular rejection and predicts a higher risk of vasculopathy progression. J Am Coll Cardiol 2009; 53:1279-86. [PMID: 19358941 DOI: 10.1016/j.jacc.2008.12.041] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2008] [Revised: 12/02/2008] [Accepted: 12/08/2008] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study was designed to investigate tissue characterization of the coronary allograft atherosclerotic plaque with virtual histology intravascular ultrasound (VH-IVUS) imaging to assess the presence and predictors of vessel wall inflammation and its significance in cardiac allograft vasculopathy (CAV) progression. BACKGROUND A unique form of accelerated atherosclerosis, CAV remains the leading cause of late morbidity and mortality in heart transplant patients. The pathogenesis of CAV is not fully elucidated. METHODS A total of 86 patients with coronary allograft vasculopathy underwent VH-IVUS examination of the left anterior descending coronary artery 3.61 +/- 3.04 years following cardiac transplantation. Based on the VH-IVUS plaque characteristics, coronary allograft plaque was divided on virtual histology intravascular ultrasound-derived "inflammatory" (VHD-IP) (necrotic core and dense calcium > or =30%) and "noninflammatory" plaque (VHD-NIP) (necrotic core and dense calcium <30%). Total rejection scores were calculated based on the 2004 International Society of Heart and Lung Transplantation rejection grading system. RESULTS In the whole study population, the mean percentage of fibrous, fibrofatty, dense calcified, and necrotic core plaques in a mean length of 62.3 +/- 17.4 mm of the left anterior descending coronary artery were 50 +/- 17%, 16 +/- 11%, 15 +/- 11%, and 18 +/- 9%, respectively. Patients with a 6-month total rejection score >0.3 had significantly higher incidence of VHD-IP than those with a 6-month total rejection score < or =0.3 (69% vs. 33%, p = 0.011). The presence of VHD-IP at baseline was associated with a significant increase in plaque volume (2.42 +/- 1.78 mm(3)/mm vs. -0.11 +/- 1.65 mm(3)/mm, p = 0.010), plaque index (7 +/- 9% vs. 0 +/- 8%, p = 0.04), and remodeling index (1.24 +/- 0.44 vs. 1.09 +/- 0.36, p = 0.030) during 12 months of follow-up when compared with the presence of VHD-NIP at baseline and during follow-up. CONCLUSIONS The presence of VHD-IP as assessed by VH-IVUS is associated with early recurrent rejection and with higher subsequent progression of CAV. A VH-IVUS assessment may add important information in the evaluation of transplant recipients.
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Murray DL, Pereira NL, Miller DV. An Unusual Presentation of Post-transplant Lymphoproliferative Disorder Mimicking Vasculitis in Heart Transplantation. J Heart Lung Transplant 2008; 27:1257-61. [DOI: 10.1016/j.healun.2008.07.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Revised: 06/09/2008] [Accepted: 07/17/2008] [Indexed: 10/21/2022] Open
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Potena L, Valantine HA. Cardiac allograft vasculopathy and insulin resistance--hope for new therapeutic targets. Endocrinol Metab Clin North Am 2008. [PMID: 17983931 DOI: 10.1016/j.ecl.2007.07.012.cardiac] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Cardiac allograft vasculopathy (CAV) is a major cause of death in patients surviving more than 1 year after heart transplantation. An important cluster of CAV risk factors occurs as a consequence of insulin resistance and manifests as part of the metabolic syndrome. This article summarizes the pathologic features of CAV and reviews the contribution of the major components of insulin resistance in CAV development and progression. It focuses on the few studies that have analyzed the impact of the individual metabolic abnormalities and inflammation and on therapeutic strategies to minimize the clinical manifestation of insulin resistance after heart transplantation.
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Affiliation(s)
- Luciano Potena
- Institute of Cardiology, Academic Hospital S.Orsola-Malpighi, via Massarenti 9, Building 21, 40138 Bologna, Italy
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Potena L, Valantine HA. Cardiac allograft vasculopathy and insulin resistance--hope for new therapeutic targets. Endocrinol Metab Clin North Am 2007; 36:965-81; ix. [PMID: 17983931 PMCID: PMC3785936 DOI: 10.1016/j.ecl.2007.07.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Cardiac allograft vasculopathy (CAV) is a major cause of death in patients surviving more than 1 year after heart transplantation. An important cluster of CAV risk factors occurs as a consequence of insulin resistance and manifests as part of the metabolic syndrome. This article summarizes the pathologic features of CAV and reviews the contribution of the major components of insulin resistance in CAV development and progression. It focuses on the few studies that have analyzed the impact of the individual metabolic abnormalities and inflammation and on therapeutic strategies to minimize the clinical manifestation of insulin resistance after heart transplantation.
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Cuda JD, Baldwin WM, Steenbergen C, Judge DP, Dropulic LK, Halushka MK. Extensive cardiac allograft vasculitis and concurrent fat necrosis 6 years after orthotopic heart transplantation. J Heart Lung Transplant 2007; 26:1212-6. [PMID: 18022091 DOI: 10.1016/j.healun.2007.07.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2007] [Revised: 07/17/2007] [Accepted: 07/18/2007] [Indexed: 11/16/2022] Open
Abstract
Coronary artery vasculitis has been described as a rare lesion in the spectrum of transplant vasculopathy or as an extension of severe acute cellular rejection. We describe a patient, 6 years after orthotopic cardiac transplantation, who developed rapid heart failure and died despite aggressive treatment, minimal cardiac rejection (ISHLT Grade 1R), and no known transplant vasculopathy. Autopsy showed a diffuse and essentially complete necrotizing vasculitis of the entire coronary vasculature involving small, medium and large vessels, with extensive fat necrosis within the pericardial space. Macrophages of the M2 phenotype were found lining the major coronary vascular lumens and infiltrating their walls. The presence of the M2 macrophage phenotype supports transplant vasculitis as part of the chronic transplant vasculopathy continuum.
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Affiliation(s)
- Jonathan D Cuda
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland 21205, USA
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Tan CD, Baldwin WM, Rodriguez ER. Update on cardiac transplantation pathology. Arch Pathol Lab Med 2007; 131:1169-91. [PMID: 17683180 DOI: 10.5858/2007-131-1169-uoctp] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2006] [Indexed: 11/06/2022]
Abstract
CONTEXT The endomyocardial biopsy is the mainstay for monitoring acute allograft rejection in heart transplantation. Objective and accurate assessment of cellular and humoral types of rejection is important to optimize immunosuppressive therapy, avoid therapeutic complications, and improve patient outcome. The grading system for evaluation of heart transplant biopsies published in 1990 was revised in 2004 after more than a decade of implementation. OBJECTIVE In this review, we focus on a practical approach to the evaluation of human heart transplant biopsies as diagnostic surgical pathologic specimens. We discuss the revised International Society of Heart and Lung Transplantation working formulation. DATA SOURCES We reviewed pertinent literature, incorporating ideas and vast experience of participants in various work groups that led to the revision of the 1990 grading system. CONCLUSIONS The grading system for cellular rejection is presented with detailed light microscopic morphology and comparison of the 1990 and 2004 International Society of Heart and Lung Transplantation working formulations. We show how the pathologic recognition of cellular rejection and antibody-mediated rejection has evolved. We emphasize the interpretation of immunostains for complement components C4d and C3d in the diagnosis of antibody-mediated rejection. Evidence of regulation of complement activation in human heart transplant biopsies is presented in this context. We also discuss the pitfalls, caveats, and artifacts in the interpretation of allograft endomyocardial biopsies. Lastly, we discuss the pathology of human cardiac allograft vasculopathy in practical detail.
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Affiliation(s)
- Carmela D Tan
- Department of Anatomic Pathology, The Cleveland Clinic, Cleveland, OH 44195, USA
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Alexander RT, Lathrop S, Vollmer R, Blue L, Russell SD, Steenbergen C. Graft Vascular Disease After Cardiac Transplantation and Its Relationship to Mean Acute Rejection Score. Arch Pathol Lab Med 2005; 129:1283-7. [PMID: 16196517 DOI: 10.5858/2005-129-1283-gvdact] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Context.—Graft vascular disease remains a significant source of morbidity and mortality in heart transplant patients. The influence of acute cellular rejection on the development of graft vascular disease is controversial.
Objective.—To determine the relationship between mean acute cellular rejection score and the presence of atherosclerosis or fibrointimal hyperplasia in cardiac allografts at autopsy.
Design.—This retrospective, autopsy-based study examined 27 heart transplant patients to evaluate for graft vascular disease. A rejection score for each patient was calculated as the average of all the rejection scores determined by endomyocardial biopsy. Gross and histologic examination of the heart was used to divide patients into 3 groups: no coronary artery disease, atherosclerosis, and fibrointimal hyperplasia. Mean rejection scores were calculated for each of these groups for all patients and patients who survived longer than 3 months. Mean rejection scores were compared by an analysis of variance and pairwise t tests.
Results.—Mean rejection scores demonstrated a trend of increasing value from no coronary disease (0.323) to atherosclerosis (0.569) to fibrointimal hyperplasia (0.835). Only fibrointimal hyperplasia had a significantly higher mean rejection score compared with patients with no coronary disease when examined in all patients (P = .01) and in patients who survived longer than 3 months (P = .049).
Conclusion.—This study showed that the development of coronary artery fibrointimal hyperplasia, but not atherosclerosis, was significantly related to mean acute rejection score.
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Atkinson C, Horsley J, Rhind-Tutt S, Charman S, Phillpotts CJ, Wallwork J, Goddard MJ. Neointimal smooth muscle cells in human cardiac allograft coronary artery vasculopathy are of donor origin. J Heart Lung Transplant 2004; 23:427-35. [PMID: 15063402 DOI: 10.1016/s1053-2498(03)00222-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2003] [Revised: 04/22/2003] [Accepted: 05/03/2003] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Transplant coronary artery vasculopathy (CAV) is a fibro-proliferative process that leads to lumen occlusion and cardiac failure. Current theories suggest that the process evolves over time in response to inflammation and proliferation of donor derived medial smooth muscle cells (SMC). Animal models of cardiac transplantation have suggested that the neointima is formed by recipient derived circulating progenitor cells. The aim of this investigation is to determine the origin of the neointimal SMC within epicardial coronary arteries from human cardiac allografts by using sex mis-matched recipients and donors, and a Y specific chromosome probe. METHODS Coronary arteries from 14 patients previously assessed histologically to have CAV were analyzed-eight male recipients of female donor organs, 2 female-to-female, and 4 male-to-male transplants. A double immunocytochemistry and in-situ hybridization technique using a Y chromosome DNA probe and either antibodies to smooth muscle actin or Ham-56 a macrophage marker were employed. RESULTS No Y chromosome bodies could be identified in the female-to-female allografts. In the 4 male donor and male recipient cases, cells positive for the Y chromosome probe were identified. In sex mis-matched transplants, female to male, inflammatory cells marked with Ham-56 were also positive for Y chromosome probe. Flattened cells positive for Y chromosome were observed just beneath the endothelial surface. When double stained, these were identified as infiltrating macrophages. No double staining smooth muscle cells and Y chromosome positive cells could be identified within the neointima. CONCLUSIONS This study confirms the source of SMC of the neointima of CAV lesions from epicardial coronary arteries to be of donor origin. In contrast to animal models, circulating progenitor cells do not appear to play a role within the neointima of human transplant CAV.
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Affiliation(s)
- Carl Atkinson
- Department of Pathology, Papworth NHS Trust Hospital, Cambridge, UK.
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Valantine-von Kaeppler HA. Role of cytomegalovirus infection in transplant arteriosclerosis and chronic rejection. Transplant Rev (Orlando) 2001. [DOI: 10.1016/s0955-470x(05)80004-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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