1
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Bergmark BA, Zelniker TA, Kim M, Mehra MR, Stewart GC, Page DS, Woodcome EL, Givertz MM. Early aspirin use, allograft rejection, and cardiac allograft vasculopathy in heart transplantation. Clin Transplant 2021; 35:e14424. [PMID: 34254366 DOI: 10.1111/ctr.14424] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 07/01/2021] [Accepted: 07/04/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Early aspirin (ASA) use after orthotopic heart transplantation (OHT) has been associated with lower rates of cardiac allograft vasculopathy (CAV). We hypothesized that the inverse association between ASA use and CAV incidence may be most pronounced in patients with allograft rejection. METHODS Patients receiving OHT at a single center 2004-2010 (n = 120) were categorized by early ASA use post-transplant (ASA use for > 6 months in the first year) and the presence of biopsy-defined acute cellular rejection (ACR) and/or antibody-mediated rejection (AMR) during 5-year follow-up. Propensity scores for ASA treatment were estimated using boosting models and applied by inverse probability of treatment weighting. The association between ASA use and time to moderate/severe CAV (ISHLT ≥ 2) was investigated. RESULTS Among patients with ACR or AMR, ASA therapy was associated with significantly lower rates of CAV≥ 2 (3.3 vs. 30.1%; P = .001; HRadj .07; 95% CI .01-.52), whereas ASA therapy was not associated with lower rates of CAV in patients with no rejection (5.6 vs. 5.3%; P = .90; HRadj 1.26; 95% CI .08-20.30; pinteraction = .09). CONCLUSIONS Early ASA use after OHT was associated with lower rates of moderate to severe CAV only in those patients with episodes of allograft rejection.
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Affiliation(s)
- Brian A Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston, MA, USA.,Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Thomas A Zelniker
- Division of Cardiology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Miae Kim
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - Mandeep R Mehra
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - Garrick C Stewart
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - Deborah S Page
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - Erica L Woodcome
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA, USA
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2
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Wang LP, Jia ZB, Liu Y, Gao Q, Cheng SJ, Jin D, Ma L, Yin XH. Inhibitory effect of wild-type P53 gene transfer on graft coronary artery disease. Transpl Immunol 2018; 48:1-9. [DOI: 10.1016/j.trim.2018.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 02/01/2018] [Accepted: 02/05/2018] [Indexed: 11/27/2022]
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3
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Abstract
Today's healthcare delivery system is challenged with an escalating number of heart failure patients who have exhausted medical therapy and overwhelmed the limits of organ transplantation. Scientific and technological advances over the last 20 years have now brought new surgical options to this vast patient population, ranging from ventricular restoration surgery to surgical gene therapy and beyond. This article reviews the myriad of surgical options that are available to these patients, their benefits and shortcomings, as well as potential future directions.
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4
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Lavine KJ, Sintek M, Novak E, Ewald G, Geltman E, Joseph S, Pfeifer J, Mann DL. Coronary collaterals predict improved survival and allograft function in patients with coronary allograft vasculopathy. Circ Heart Fail 2013; 6:773-84. [PMID: 23709657 DOI: 10.1161/circheartfailure.113.000277] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite improvements in the care of patients who have received cardiac transplants, coronary allograft vasculopathy (CAV) remains the most prevalent cause of late allograft failure and cardiac mortality. Few proven therapies are available for this important disease. The presence of coronary collaterals imparts a favorable prognosis in patients with native ischemic heart disease; however, the impact of collaterals in CAV is unknown. METHODS AND RESULTS To determine whether the development of coronary collaterals is associated with improved outcomes in patients with CAV, we performed a retrospective analysis of patients followed in the heart transplant program at Barnes Jewish Hospital from 1994 to 2008. The primary end points included all cause mortality and the composite of all cause mortality, retransplantation, and inotrope dependence. We screened 485 patients and identified 59 (12%) subjects with moderate-to-severe CAV. Angiographically visible coronary collaterals were present in 34 (57%) subjects. Kaplan-Meier and Cox multivariable analyses revealed that patients with collaterals had reduced incidence of all cause mortality (hazard ratio, 0.20; P<0.001) and the composite end point (hazard ratio, 0.17; P<0.001). In addition, patients with collaterals had less severe heart failure symptoms as measured by New York Heart Association class. Immunostaining of biopsy specimens revealed that among patients with CAV, the presence of coronary collaterals correlated with increased microvascular density, reduced fibrosis, and decreased left ventricular end-diastolic pressure. CONCLUSIONS Together, these data demonstrate that the presence of coronary collaterals predicts a favorable prognosis in patients with CAV and suggests that interventions aimed at promoting collateral and microvascular growth may serve as effective therapies for this disease.
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Affiliation(s)
- Kory J Lavine
- Division of Cardiology, Center for Cardiovascular Research, Washington University School of Medicine, St Louis, MO 63110, USA.
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5
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Kwon MH, Wong SY, Ardehali A, Laks H, Zhang ZK, Deng MC, Shemin RJ. Primary graft dysfunction does not lead to increased cardiac allograft vasculopathy in surviving patients. J Thorac Cardiovasc Surg 2012; 145:869-73. [PMID: 23083793 DOI: 10.1016/j.jtcvs.2012.09.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Revised: 07/16/2012] [Accepted: 09/13/2012] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Early injury is associated with the development of cardiac allograft vasculopathy in heart transplantation. We examined whether adult heart transplant recipients surviving primary graft dysfunction were more susceptible to the development of cardiac allograft vasculopathy than their nonprimary graft dysfunction counterparts. METHODS A total of 857 patients who underwent heart transplantation between January 1994 and December 2008 at our institution were reviewed. Primary graft dysfunction was defined as the need for extracorporeal membrane oxygenation, open chest, or intra-aortic balloon pump placement within 72 hours of transplantation. Cardiac allograft vasculopathy was defined as ≥50% coronary artery stenosis in any vessel. Allograft survival was defined by patient death or need for retransplantation. RESULTS Completed follow-up was available for 32 patients in the primary graft dysfunction group and 701 patients in the nonprimary graft dysfunction group. Mean recipient ages (56 years vs 55 years, respectively; P = .50) and ischemic times (220 minutes vs 208 minutes, respectively; P = .35) were similar. Donor age was significantly higher in the primary graft dysfunction group (38 years vs 32 years, P = .02). Five-year survivals for the primary graft dysfunction and nonprimary graft dysfunction groups were 46.9% versus 78.9% (P < .001). Conditional 5-year survivals in patients surviving the first year were 78.9% and 88.3% for the primary graft dysfunction and nonprimary graft dysfunction groups, respectively (P = .18). Within a 30-day postoperative period, there were more deaths in the primary graft dysfunction group (28.1% vs 2.3%, P < .0001) and more retransplants (6.25% vs 0%, P = .002). Of the patients surviving past 30 days, only 2 (8.7%) of the primary graft dysfunction patients developed cardiac allograft vasculopathy versus 144 (21.0%) in the nonprimary graft dysfunction group (P < .001). CONCLUSIONS Primary graft dysfunction was associated with lower 30-day, 1-year, and 5-year allograft survival rates. Surviving patients, however, did not show increased tendency toward cardiac allograft vasculopathy development.
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Affiliation(s)
- Murray H Kwon
- Division of Cardiothoracic Surgery, Department of Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA.
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6
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Magri CJ, Xuereb RG. Stress echocardiography vs nuclear stress imaging in clinical cardiology. Br J Hosp Med (Lond) 2012; 73:324-30. [DOI: 10.12968/hmed.2012.73.6.324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Stress echocardiography and nuclear stress imaging are important non-invasive tools in clinical cardiology. This review discusses the uses, strengths and limitations of these imaging modalities and looks at whether stress echocardiography can actually replace nuclear stress imaging.
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Affiliation(s)
- Caroline J Magri
- Department of Cardiac Services, Mater Dei Hospital, Tal-Qroqq, Msida MSD 2090
| | - Robert G Xuereb
- Department of Cardiac Services, Mater Dei Hospital, Tal-Qroqq, Msida MSD 2090, Malta
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7
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Early cardiac allograft vasculopathy: are the viruses to blame? Case Rep Med 2012; 2012:734074. [PMID: 22701124 PMCID: PMC3369528 DOI: 10.1155/2012/734074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 04/11/2012] [Indexed: 11/23/2022] Open
Abstract
This paper describes a case of early (7 months after transplant) cardiac allograft vasculopathy. This-43-year-old (CMV positive, EBV negative) female patient underwent an orthotopic heart transplant with a (CMV negative, EBV positive) donor heart. She had a history of herpes zoster infection and postherpetic neuralgia in the past. The patient's panel reactive antibodies had been almost undetectable on routine surveillance testing, and her surveillance endomyocardial biopsies apart from a few episodes of mild-to-moderate acute cellular rejection (treated adequately with steroids) never showed any evidence of humoral rejection. The postoperative course was complicated by multiple admissions for upper respiratory symptoms, and the patient tested positive for entero, rhino, and coronaviruses serologies. During her last admission (seven months postoperatively) the patient developed mild left ventricular dysfunction with an ejection fraction of 40%. The patient's endomyocardial biopsy done at that time revealed concentric intimal proliferation and inflammation resulting in near-total luminal occlusion in the epicardial and the intramyocardial coronary vessels, suggestive of graft vasculopathy with no evidence of rejection, and the patient had a fatal ventricular arrhythmia.
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8
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Jui HY, Lin CH, Hsu WT, Liu YR, Hsu RB, Chiang BL, Tseng WYI, Chen MF, Wu KK, Lee CM. Autologous mesenchymal stem cells prevent transplant arteriosclerosis by enhancing local expression of interleukin-10, interferon-γ, and indoleamine 2,3-dioxygenase. Cell Transplant 2012; 21:971-84. [PMID: 22449499 DOI: 10.3727/096368911x627525] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Transplant arteriosclerosis (TA) remains the major limitation of long-term graft survival in heart transplantation despite the advances in immunosuppressants. Mesenchymal stem cells (MSCs) have been demonstrated to suppress allogeneic immune responses by numerous in vitro studies. However, the immunomodulatory effects of MSCs in vivo are controversial and the underlying molecular mechanisms are not conclusive. In this study, we investigated the therapeutic potential of autologous bone marrow-derived MSCs on TA in a porcine model of femoral artery transplantation. MSCs or saline were injected into the soft tissue surrounding the arterial grafts immediately postanastomosis. Four weeks after transplantation, neointimal formation increased significantly in untreated allografts compared with the MSC-treated grafts as assessed by intravascular ultrasound (maximum luminal area stenosis: 40 ± 12% vs. 18 ± 6%, p < 0.001). Grafts harvested at 4 weeks showed dense perivascular lymphocyte infiltration accompanied by significant intimal hyperplasia in the untreated but not in the MSC-treated allografts. Serial angiographic examination showed that all of the untreated allografts became occluded at the 8th week whereas the majority of the MSC-treated grafts remained patent at the 12th week posttransplantation (n = 12 each group, p < 0.001). Quantitative PCR analysis revealed that Foxp3 expression was comparable between the untreated and the MSC-treated groups. However, expression of interleukin-10 (IL-10), interferon-γ (IFN-γ), and indoleamine 2,3-dioxygenase (IDO) was increased significantly in the MSC-treated allografts compared with that in the allograft controls (p = 0.021 for IL-10, p = 0.003 for IFN-γ, and p = 0.008 for IDO). In conclusion, local delivery of autologous MSCs alleviates TA by inducing allograft tolerance via enhanced expression of IL-10, IFN-γ, and IDO but not Foxp3-positive cells in the vessel wall. These results suggest that MSCs induce immune tolerance by activating the type 1 regulatory T-like cells.
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Affiliation(s)
- Hsiang-Yiang Jui
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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9
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Fuchs U, Zittermann A, Hakim-Meibodi K, Börgermann J, Schulz U, Gummert J. Everolimus Plus Dosage Reduction of Cyclosporine in Cardiac Transplant Recipients with Chronic Kidney Disease: A Two-Year Follow-up Study. Transplant Proc 2011; 43:1839-46. [DOI: 10.1016/j.transproceed.2010.12.055] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Accepted: 12/20/2010] [Indexed: 11/16/2022]
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10
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Long-Term Maintenance Therapy for Post–Cardiac Transplant Monoclonal Lymphoproliferative Disorder: Caveat Mammalian Target of Rapamycin. Transplant Proc 2011; 43:1893-9. [DOI: 10.1016/j.transproceed.2011.03.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 02/25/2011] [Accepted: 03/09/2011] [Indexed: 11/22/2022]
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11
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Tay AE, Faddy S, Lim S, Walker BD, Kuchar D, Thorburn CW, Macdonald P, Keogh A, Kotlyar E, Farnsworth A, Hayward C, Jansz P, Granger E, Spratt P, Subbiah RN. Permanent Pacing for Late-Onset Atrioventricular Block in Patients with Heart Transplantation: A Single Center Experience. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 34:72-5. [PMID: 20946303 DOI: 10.1111/j.1540-8159.2010.02906.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Andre E Tay
- Department of Cardiology and Cardiac Electrophysiology, St Vincent's Hospital, Sydney, Australia
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12
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Barker AK, McDaniel DO, Zhou X, He Z, Aru G, Thomas T, Moore CK. Combined Analysis of Allograft Inflammatory Factor-1, Interleukin-18, and Toll-Like Receptor Expression and Association with Allograft Rejection and Coronary Vasculopathy. Am Surg 2010. [DOI: 10.1177/000313481007600834] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In cardiac transplantation settings, the initial myocardial ischemia and reperfusion may cause myocyte tissue injury and the release of allograft inflammatory factor-1 (AIF-1). This in part may trigger the innate immune response through the modulation of Toll-like receptor-2 (TLR-2) and AIF-1 expression and function, causing the release of proinflammatory cytokines. The goal was to demonstrate these markers in the peripheral blood and biopsy specimen from recipients with cardiac allograft rejection and coronary vasculopathy (CV). Peripheral blood and endomyocardial specimens were tested by reverse transcriptase-polymerase chain reaction and immunohistochemistry stains for identification of TLR-2, -4, interleukin-18, and AIF-1 markers and analyzed against clinical rejection grades for rejection. The differences for mRNA transcript levels were determined by one-way analysis of variance. The mRNA expression levels were significantly varied for TLR-2 in monocytes with different rejection grades ( P < 0.0001). The mean ± SEM level of mRNA expression for 3A grade rejection was 64.21 ± 3.8; grade 1A, 38.4 ± 3.5; and for Grade 0 was 38.46 ± 2.8. The TLR-4 mRNA expression was increased but the specificity was not statistically significant. The TLR-2 immunoreactivity was strongly detected in infiltrating mononuclear cells and cardiac myocytes in Grade 3A rejection. AIF-1 expression was increased significantly in the group with 3A rejection and Grade III CV as compared with Grade 0 or 1A. Interleukin-18 receptors were strongly detected in Grade 3A rejection and CV. The expression profiles of AIF-1, TLR-2, and interleukin-18 were correlated with biopsy-proven allograft rejection in both peripheral blood and local tissue, suggesting a potential for diagnostic biomarkers for early detection of allograft rejection.
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Affiliation(s)
- Andrea K. Barker
- Departments of Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - D. Olga McDaniel
- Departments of Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Xinchun Zhou
- Pathology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Zelda He
- Pathology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Giorgio Aru
- Departments of Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Tammy Thomas
- Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Charles K. Moore
- Medicine, University of Mississippi Medical Center, Jackson, Mississippi
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13
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Sánchez-Lázaro IJ, Almenar L, Martínez-Dolz L, Buendía-Fuentes F, Agüero J, Navarro-Manchón J, Vicente JL, Salvador A. A prospective randomized study comparing cyclosporine versus tacrolimus combined with daclizumab, mycophenolate mofetil, and steroids in heart transplantation. Clin Transplant 2010; 25:606-13. [PMID: 20682020 DOI: 10.1111/j.1399-0012.2010.01309.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ignacio J Sánchez-Lázaro
- Heart Failure and Transplantation Unit, Cardiology Department, Hospital Universitario La Fe, Valencia, Spain.
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14
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Graham JA, Wilkinson RA, Hirohashi T, Chase CM, Colvin RB, Madsen JC, Fishman JA, Russell PS. Viral infection induces de novo lesions of coronary allograft vasculopathy through a natural killer cell-dependent pathway. Am J Transplant 2009; 9:2479-84. [PMID: 19843029 PMCID: PMC2766593 DOI: 10.1111/j.1600-6143.2009.02801.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Viral infections including those due to cytomegalovirus have been associated with accelerated cardiac allograft vasculopathy (CAV) in clinical trials and some animal models. Evidence demonstrating a direct causal relationship between such infections and de novo formation of coronary vascular lesions is lacking. Heterotopic murine cardiac transplants were performed in a parental to F1 combination in animals lacking both T- and B-lymphocytes (RAG(-/-)). Coronary vasculopathy developed almost exclusively in the presence of recipient infection with lymphocytic choriomeningitis virus but not in uninfected controls. This process was also dependent upon the presence of natural killer (NK) cells as depletion of NK cells abrogated the process. These data show that a viral infection in its native host, and not previously implicated in the production of CAV, can contribute to the development of advanced coronary vascular lesions in cardiac allotransplants in mice. These data also suggest that virus-induced CAV can develop via an NK-cell-dependent pathway in the absence of T- and B-lymphocytes.
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Affiliation(s)
- Jay A. Graham
- Transplantation Research and Cardiac Surgical Divisions of the Department of Surgery of the Harvard Medical School at the Massachusetts General Hospital, Boston, MA 02114 USA
| | - Robert A. Wilkinson
- Transplant Infectious Disease Program, Infectious Disease Division, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Tsutomu Hirohashi
- Transplantation Research and Cardiac Surgical Divisions of the Department of Surgery of the Harvard Medical School at the Massachusetts General Hospital, Boston, MA 02114 USA
| | - Catharine M. Chase
- Transplantation Research and Cardiac Surgical Divisions of the Department of Surgery of the Harvard Medical School at the Massachusetts General Hospital, Boston, MA 02114 USA
| | - Robert B. Colvin
- Department of Pathology of the Harvard Medical School at the Massachusetts General Hospital, Boston, MA 02114 USA
| | - Joren C. Madsen
- Transplantation Research and Cardiac Surgical Divisions of the Department of Surgery of the Harvard Medical School at the Massachusetts General Hospital, Boston, MA 02114 USA
| | - Jay A. Fishman
- Transplant Infectious Disease Program, Infectious Disease Division, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Paul S. Russell
- Transplantation Research and Cardiac Surgical Divisions of the Department of Surgery of the Harvard Medical School at the Massachusetts General Hospital, Boston, MA 02114 USA
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15
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The Effects of C-Reactive Protein, Interleukin-6, and Tumor Necrosis Factor-α in Rat Allograft Adventitial Inflammation and Allograft Arteriosclerosis. Transplant Proc 2009; 41:3909-12. [DOI: 10.1016/j.transproceed.2009.06.190] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Accepted: 06/01/2009] [Indexed: 11/15/2022]
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16
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Korosoglou G, Osman NF, Dengler TJ, Riedle N, Steen H, Lehrke S, Giannitsis E, Katus HA. Strain-encoded cardiac magnetic resonance for the evaluation of chronic allograft vasculopathy in transplant recipients. Am J Transplant 2009; 9:2587-96. [PMID: 19843034 DOI: 10.1111/j.1600-6143.2009.02769.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The aim of our study was to investigate the ability of Strain-Encoded magnetic resonance imaging (MRI) to detect cardiac allograft vasculopathy (CAV) in heart transplantation (HTx)-recipients. In consecutive subjects (n = 69), who underwent cardiac catheterization, MRI was performed for quantification of myocardial strain and perfusion reserve. Based on angiographic findings subjects were classified: group A including patients with normal vessels; group B, patients with stenosis <50%; and group C, patients with severe CAV (stenosis >or= 50%). Significant correlations were observed between myocardial perfusion reserve with peak systolic strain (r =-0.53, p < 0.001) and with mean diastolic strain rate (r = 0.82, p < 0.001). Peak systolic strain and strain rate were significantly reduced only in group C, while mean diastolic strain rate and myocardial perfusion reserve were already reduced in group B and A. Myocardial perfusion reserve and mean diastolic strain rate had higher accuracy for the detection of CAV (AUC = 0.95, 95% CI = 0.87-0.99 and AUC = 0.93, 95% CI = 0.84-0.98, respectively) and followed peak systolic strain and strain rate (AUC = 0.80, 95% CI = 0.69-0.89 and AUC = 0.78, 95% CI = 0.67-0.87, respectively). Besides the quantification of myocardial perfusion, the estimation of the diastolic strain rate is a useful parameter for CAV assessment. In combination with the clinical evaluation, these parameters may be effective tools for the routine surveillance of HTx-recipients.
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Affiliation(s)
- G Korosoglou
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany.
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17
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Delgado JF, Manito N, Segovia J, Almenar L, Arizón JM, Campreciós M, Crespo-Leiro MG, Díaz B, González-Vílchez F, Mirabet S, Palomo J, Roig E, de la Torre JM. The use of proliferation signal inhibitors in the prevention and treatment of allograft vasculopathy in heart transplantation. Transplant Rev (Orlando) 2009; 23:69-79. [PMID: 19298938 DOI: 10.1016/j.trre.2009.01.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Cardiac allograft vasculopathy (CAV) currently represents one of the most important causes of long-term morbidity and mortality in the heart transplant population. In well-designed studies with de novo patients, the use of proliferation signal inhibitors (PSIs; everolimus and sirolimus) has been shown to significantly prevent the intimal growth of graft coronary arteries in comparison to other immunosuppressive regimens, reducing the incidence of vasculopathy at 12 and 24 months. In addition, conversion to PSIs in maintenance patients with established CAV has also shown promising results in the reduction of the progression of the disease and its clinical consequences. For these reasons the interest shown by various transplantation units in the potential role of PSIs in this field is growing. The aim of the present article is to review the information obtained to date on the use of PSIs in heart transplant recipients, both in the prevention and the treatment of CAV. The principal published recommendations on the introduction and appropriate management of these drugs in clinical practice are also collected, as well as certain recommendations given by the authors based on their experience.
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Affiliation(s)
- Juan F Delgado
- Unidad de Insuficiencia Cardiaca y Trasplante, Servicio de Cardiología, Hospital 12 de Octubre, 28041 Madrid, Spain.
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18
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Albumin Augmentation Improves Condition of Guinea Pig Hearts After 4 hr of Cold Ischemia. Transplantation 2009; 87:956-65. [DOI: 10.1097/tp.0b013e31819c83b5] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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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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20
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Medium-Term Outcomes in Cardiac Transplant Recipients in a Single Cardiac Transplant Center in Taiwan. Transplant Proc 2008; 40:2626-8. [DOI: 10.1016/j.transproceed.2008.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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Collins MJ, Moainie SL, Griffith BP, Poston RS. Preserving and evaluating hearts with ex vivo machine perfusion: an avenue to improve early graft performance and expand the donor pool. Eur J Cardiothorac Surg 2008; 34:318-25. [PMID: 18539041 PMCID: PMC2649718 DOI: 10.1016/j.ejcts.2008.03.043] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2007] [Revised: 03/04/2008] [Accepted: 03/06/2008] [Indexed: 11/21/2022] Open
Abstract
Cardiac transplantation remains the first choice for the surgical treatment of end stage heart failure. An inadequate supply of donor grafts that meet existing criteria has limited the application of this therapy to suitable candidates and increased interest in extended criteria donors. Although cold storage (CS) is a time-tested method for the preservation of hearts during the ex vivo transport interval, its disadvantages are highlighted in hearts from the extended criteria donor. In contrast, transport of high-risk hearts using hypothermic machine perfusion (MP) provides continuous support of aerobic metabolism and ongoing washout of metabolic byproducts. Perhaps more importantly, monitoring the organ's response to this intervention provides insight into the viability of a heart initially deemed as extended criteria. Obviously, ex vivo MP introduces challenges, such as ensuring homogeneous tissue perfusion and avoiding myocardial edema. Though numerous groups have experimented with this technology, the best perfusate and perfusion parameters needed to achieve optimal results remain unclear. In the present review, we outline the benefits of ex vivo MP with particular attention to how the challenges can be addressed in order to achieve the most consistent results in a large animal model of the ideal heart donor. We provide evidence that MP can be used to resuscitate and evaluate hearts from animal and human extended criteria donors, including the non-heart beating donor, which we feel is the most compelling argument for why this technology is likely to impact the donor pool.
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Affiliation(s)
- Michael J. Collins
- Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical Center, N4W94 22 S. Greene St., Baltimore, MD, 21201, United States
| | - Sina L. Moainie
- Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical Center, N4W94 22 S. Greene St., Baltimore, MD, 21201, United States
| | - Bartley P. Griffith
- Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical Center, N4W94 22 S. Greene St., Baltimore, MD, 21201, United States
| | - Robert S. Poston
- Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical Center, N4W94 22 S. Greene St., Baltimore, MD, 21201, United States
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Sinha SS, Pham MX, Vagelos RH, Perlroth MG, Hunt SA, Lee DP, Valantine HA, Yeung AC, Fearon WF. Effect of rapamycin therapy on coronary artery physiology early after cardiac transplantation. Am Heart J 2008; 155:889.e1-6. [PMID: 18440337 DOI: 10.1016/j.ahj.2008.02.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2007] [Accepted: 02/12/2008] [Indexed: 01/22/2023]
Abstract
BACKGROUND Rapamycin has been shown to reduce anatomical evidence of cardiac allograft vasculopathy, but its effect on coronary artery physiology is unknown. METHODS Twenty-seven patients without angiographic evidence of coronary artery disease underwent measurement of fractional flow reserve (FFR), coronary flow reserve (CFR), and the index of microcirculatory resistance (IMR) within 8 weeks and then 1 year after transplantation using a pressure sensor/thermistor-tipped guidewire. Measurements were compared between consecutive patients who were on rapamycin for at least 3 months during the first year after transplantation (rapamycin group, n = 9) and a comparable group on mycophenolate mofetil (MMF) instead (MMF group, n = 18). RESULTS At baseline, there was no significant difference in FFR, CFR, or IMR between the 2 groups. At 1 year, FFR declined significantly in the MMF group (0.87 +/- 0.06 to 0.82 +/- 0.06, P = .009) but did not change in the rapamycin group (0.91 +/- 0.05 to 0.89 +/- 0.04, P = .33). Coronary flow reserve and IMR did not change significantly in the MMF group (3.1 +/- 1.7 to 3.2 +/- 1.0, P = .76; and 27.5 +/- 18.1 to 19.1 +/- 7.6, P = .10, respectively) but improved significantly in the rapamycin group (2.3 +/- 0.8 to 3.8 +/- 1.4, P < .03; and 27.0 +/- 11.5 to 17.6 +/- 7.5, P < .03, respectively). Multivariate regression analysis revealed that rapamycin therapy was an independent predictor of CFR and FFR at 1 year after transplantation. CONCLUSION Early after cardiac transplantation, rapamycin therapy is associated with improved coronary artery physiology involving both the epicardial vessel and the microvasculature.
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23
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Musameh MD, Green CJ, Mann BE, Fuller BJ, Motterlini R. Improved myocardial function after cold storage with preservation solution supplemented with a carbon monoxide-releasing molecule (CORM-3). J Heart Lung Transplant 2008; 26:1192-8. [PMID: 18022087 DOI: 10.1016/j.healun.2007.08.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2007] [Revised: 07/05/2007] [Accepted: 08/17/2007] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Carbon monoxide-releasing molecules (CO-RMs) are pharmacologically active as they protect against cardiac graft rejection and cold ischemia-mediated renal dysfunction. We investigated the cardioprotective role of carbon monoxide (CO) released from CORM-3 against cold ischemia-mediated injury in the heart and evaluated its potential application in the clinical setting of cardiac transplantation. METHODS Isolated rat hearts underwent cold ischemic storage for 4 or 6 hours using St Thomas Hospital solution that was supplemented with either CORM-3 (50 mumol/liter) or its inactive counterpart (iCORM-3), which does not release CO. Hearts were then reperfused. Both functional parameters and release of cardiac enzymes were assessed. RESULTS Addition of CORM-3 to the preservation solution resulted in a significant improvement in systolic and diastolic function as well as coronary flow when compared with hearts treated with iCORM-3. In addition, lower levels of the cardiac enzymes creatine kinase and lactate dehydrogenase were measured in the perfusate of hearts stored with CORM-3. CONCLUSIONS The improved functional recovery and reduced enzyme release after cardiac cold storage with CORM-3, but not iCORM-3, indicate that CO is the main mediator of myocardial protection. Thus, CO-RMs can be used as adjuvants to improve the preservation of hearts for transplantation.
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Affiliation(s)
- Muntaser D Musameh
- Department of Surgery, Royal Free and University College London Medical School, Hampstead, London, UK
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25
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Pratschke J, Weiss S, Neuhaus P, Pascher A. Review of nonimmunological causes for deteriorated graft function and graft loss after transplantation. Transpl Int 2008; 21:512-22. [PMID: 18266771 DOI: 10.1111/j.1432-2277.2008.00643.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Various factors determine the graft- and patient survival after transplantation. HLA-matching and immunological factors are of importance for the short- and long-term survival. Apart from these obvious determinants, nonimmunological factors play an important role in defining the baseline organ quality as well as the recipients' status. The influence of these parameters on graft- and patient survival is still underestimated and is a topic of debate. On account of the increasing acceptance of marginal-donor organs these events are of increasing importance for graft survival and long-term function. We review nonimmunological causes for deteriorated graft function and graft loss after solid organ transplantation.
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Affiliation(s)
- Johann Pratschke
- Department of General, Visceral and Transplantation Surgery, Universitätsmedizin Berlin, Berlin, Germany.
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26
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Tenderich G, Fuchs U, Zittermann A, Muckelbauer R, Berthold HK, Koerfer R. Comparison of sirolimus and everolimus in their effects on blood lipid profiles and haematological parameters in heart transplant recipients. Clin Transplant 2007; 21:536-43. [PMID: 17645716 DOI: 10.1111/j.1399-0012.2007.00686.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The mTOR (mammalian target of rapamycin) inhibitors sirolimus (SRL) and everolimus (EVL) are potent immunosuppressive agents, which allow reducing the dose of the nephrotoxic calcineurin inhibitors cyclosporin and tacrolimus (TAC) in solid organ transplant recipients. However, there is evidence that mTOR inhibitors may lead to myelosuppression and dyslipidemia/hyperlipidemia. We therefore performed a retrospective analysis in heart transplant recipients with renal insufficiency, who received 3.0 mg/d SRL (SRL group; n = 28) or 1.5 mg/d EVL (EVL group; n = 27) each in combination with a reduced TAC dose for at least one yr. Fewer cardiac rejections, but a similar rate of infections occurred in the EVL group compared with the SRL group indicating that the administered EVL dose resulted in a potent immunosuppression. Serum triglyceride and total cholesterol concentrations rose significantly in the SRL group but not in the EVL group. In the SRL group only, the frequency of statin use increased significantly during follow-up. The EVL group showed a significant rise in HDL cholesterol levels during follow-up. There was a slight transient fall in haemoglobin concentrations in the SRL group but not in the EVL group. Leucocyte counts fell significantly in both study groups. However, no cases of leucopenia and also no cases of thrombopenia occurred. In summary, we could demonstrate that in heart transplant recipients with renal insufficiency the introduction of 1.5 mg/d EVL in combination with a reduced TAC dose is effective in preventing cardiac rejections and has less adverse effects on lipid metabolism than the usually prescribed SRL dose, whereas both therapy regimens are not associated with major haematological side-effects.
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Affiliation(s)
- Gero Tenderich
- Department of Cardio-Thoracic Surgery, Heart Center North-Rhine Westfalia, Ruhr University of Bochum, Bad Oeynhausen, Germany.
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27
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Affiliation(s)
- L B Balsam
- Stanford University School of Medicine, Department of Cardiothoracic Surgery, Falk Cardiovascular Research Building, 300 Pasteur Drive, Stanford, CA 94305, USA.
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28
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Koyanagi T, Noguchi K, Ootani A, Inagaki K, Robbins RC, Mochly-Rosen D. Pharmacological inhibition of epsilon PKC suppresses chronic inflammation in murine cardiac transplantation model. J Mol Cell Cardiol 2007; 43:517-22. [PMID: 17655859 DOI: 10.1016/j.yjmcc.2007.06.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2007] [Revised: 05/17/2007] [Accepted: 06/05/2007] [Indexed: 01/19/2023]
Abstract
Epsilon protein kinase C (epsilonPKC) plays pivotal roles in myocardial infarction and in heart failure. Although cardiac transplantation is a well-established therapy for severe heart failure, allograft rejection and host inflammatory responses limit graft function and reduce life expectancy. Here we determined whether sustained epsilonPKC inhibition beginning 3 days after transplantation suppress allograft rejection and improve cardiac transplantation using a murine heterotopic transplantation model. Hearts of FVB mice (H-2(q)) were transplanted into C57BL/6 mice (H-2(b)). Delivery of the epsilonPKC inhibitor, TAT(47-57)-epsilonV1-2 (epsilonV1-2, n=9, 20 mg/kg/day), or the carrier control peptide, TAT(47-57) (TAT, n=8), by osmotic pump began 3 days after transplantation and continued for the remaining 4 weeks. epsilonV1-2 treatment significantly improved the beating score throughout the treatment. Infiltration of macrophages and T cells into the cardiac grafts was significantly reduced and parenchymal fibrosis was decreased in animals treated with epsilonV1-2 as compared with control treatment. Finally, the rise in pro-fibrotic cytokine, TGF-beta and monocyte recruiting chemokine MCP-1 levels was almost abolished by epsilonV1-2 treatment, whereas the rise in PDGF-BB level was unaffected. These data suggest that epsilonPKC activity contributes to the chronic immune response in cardiac allograft and that an epsilonPKC-selective inhibitor, such as epsilonV1-2, could augment current therapeutic strategies to suppress inflammation and prolong graft survival in humans.
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Affiliation(s)
- Tomoyoshi Koyanagi
- Department of Chemical and Systems Biology, Stanford University School of Medicine CCSR, Rm 3145A, 269 Campus Drive Stanford, CA 94305-5174, USA
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Abstract
PURPOSE OF REVIEW Graft coronary artery disease is the leading cardiac cause of death in patients who have undergone cardiac transplantation. Due to denervation, classic symptoms of angina are not reliable. Many transplant centers have a protocol of routine annual surveillance cardiac angiography because treatment options are limited, especially with advanced disease. Angiography is an assessment of the arterial lumen, however, and can miss nonfocal disease. This paper reviews invasive and noninvasive diagnostic tools for graft coronary artery disease. Intravascular ultrasound is the most sensitive, but the cost and lack of widespread expertise make it unpopular. Noninvasive techniques have been studied. An ideal test would be sufficiently sensitive to detect disease and allow for prognostic information. Dobutamine echocardiography is the most sensitive noninvasive test but can have a high false-positive rate. It is also not universally available. Exercise nuclear imaging is specific and can be used as a confirmatory test in patients with positive dobutamine echocardiograms. RECENT FINDINGS Computed tomographic imaging and cardiac magnetic resonance imaging are exciting new modalities but require further study. SUMMARY There is no test sensitive and specific enough yet that can be confidently used to replace coronary angiography.
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Affiliation(s)
- Malek Kass
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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30
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Segovia J, Gómez-Bueno M, Alonso-Pulpón L. Treatment of allograft vasculopathy in heart transplantation. Expert Opin Pharmacother 2006; 7:2369-83. [PMID: 17109612 DOI: 10.1517/14656566.7.17.2369] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Cardiac allograft vasculopathy remains one of the main causes of morbidity and mortality after heart transplantation, although its impact is becoming somewhat smaller as prophylactic measures are implemented. Advances in the understanding of the molecular and cellular mechanisms involved in the genesis and development of cardiac allograft vasculopathy are opening ways for new diagnostic and therapeutic strategies. Successful prophylaxis of the early stages of the disease has been demonstrated with the use of newer immunosuppressive agents, such as sirolimus and everolimus, that will probably be included in future protocols. For most patients with established cardiac allograft vasculopathy, currently available revascularisation methods and retransplantation are not appropriate options. Antiproliferative agents could provide significant improvement in terms of symptom relief and prognosis, but their definite value must be proven in well-designed trials.
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Affiliation(s)
- Javier Segovia
- Unidad de Trasplante Cardiaco, Hospital Universitario Puerta de Hierro, C/S. Martín de Porres, 4, 28035 Madrid, Spain.
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31
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Cardiac Allograft Vasculopathy: Differences in De Novo and Maintenance Heart Transplant Recipients. Transplantation 2006. [DOI: 10.1097/01.tp.0000243150.89762.fc] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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32
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Boettger R, Lee J, Rifkin C, Kayser S. Heart transplantation and altered drug response, part I: heart transplantation and innervation. PROGRESS IN CARDIOVASCULAR NURSING 2006; 21:100-3. [PMID: 16760694 DOI: 10.1111/j.0889-7204.2006.04983.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Affiliation(s)
- Rebecca Boettger
- Department of Pharmaceutical Services, School of Pharmacy, University of California San Francisco, CA 94143-0622, USA
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