1
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Godown J, Cantor R, Koehl D, Cummings E, Vo JB, Dodd DA, Lytrivi I, Boyle GJ, Sutcliffe DL, Kleinmahon JA, Shih R, Urschel S, Das B, Carlo WF, Zuckerman WA, West SC, McCulloch MA, Zinn MD, Simpson KE, Kindel SJ, Szmuszkovicz JR, Chrisant M, Auerbach SR, Carboni MP, Kirklin JK, Hsu DT. Practice variation in the diagnosis of acute rejection among pediatric heart transplant centers: An analysis of the pediatric heart transplant society (PHTS) registry. J Heart Lung Transplant 2021; 40:1550-1559. [PMID: 34598871 DOI: 10.1016/j.healun.2021.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/01/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Freedom from rejection in pediatric heart transplant recipients is highly variable across centers. This study aimed to assess the center variation in methods used to diagnose rejection in the first-year post-transplant and determine the impact of this variation on patient outcomes. METHODS The PHTS registry was queried for all rejection episodes in the first-year post-transplant (2010-2019). The primary method for rejection diagnosis was determined for each event as surveillance biopsy, echo diagnosis, or clinical. The percentage of first-year rejection events diagnosed by surveillance biopsy was used to approximate the surveillance strategy across centers. Methods of rejection diagnosis were described and patient outcomes were assessed based on surveillance biopsy utilization among centers. RESULTS A total of 3985 patients from 56 centers were included. Of this group, 873 (22%) developed rejection within the first-year post-transplant. Surveillance biopsy was the most common method of rejection diagnosis (71.7%), but practices were highly variable across centers. The majority (73.6%) of first rejection events occurred within 3-months of transplantation. Diagnosis modality in the first-year was not independently associated with freedom from rejection, freedom from rejection with hemodynamic compromise, or overall graft survival. CONCLUSIONS Rejection in the first-year after pediatric heart transplant occurs in 22% of patients and most commonly in the first 3 months post-transplant. Significant variation exists across centers in the methods used to diagnose rejection in pediatric heart transplant recipients, however, these variable strategies are not independently associated with freedom from rejection, rejection with hemodynamic compromise, or overall graft survival.
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Affiliation(s)
- J Godown
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.
| | - R Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - D Koehl
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - E Cummings
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - J B Vo
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - D A Dodd
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - I Lytrivi
- Pediatric Cardiology, Columbia University Medical Center, New York, New York
| | - G J Boyle
- Pediatric Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - D L Sutcliffe
- Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - J A Kleinmahon
- Pediatric Cardiology, Ochsner Hospital for Children, New Orleans, Louisiana
| | - R Shih
- Pediatric Cardiology, University of Florida, Gainesville, Florida
| | - S Urschel
- Pediatric Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - B Das
- Pediatric Cardiology, University of Mississippi Medical Center, Jackson, Mississippi
| | - W F Carlo
- Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - W A Zuckerman
- Pediatric Cardiology, Columbia University Medical Center, New York, New York
| | - S C West
- Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - M A McCulloch
- Pediatric Cardiology, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - M D Zinn
- Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - K E Simpson
- Pediatrics, Division of Cardiology, University of Colorado Anschutz Medical Campus Children's Hospital Colorado, Aurora, Colorado
| | - S J Kindel
- Pediatric Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - J R Szmuszkovicz
- Pediatric Cardiology, Children's Hospital of Los Angeles, Los Angeles, California
| | - M Chrisant
- Pediatric Cardiology, Joe DiMaggio Children's Hospital, Hollywood, Florida
| | - S R Auerbach
- Pediatrics, Division of Cardiology, University of Colorado Anschutz Medical Campus Children's Hospital Colorado, Aurora, Colorado
| | - M P Carboni
- Pediatric Cardiology, Duke Children's Hospital, Durham, North Carolina
| | - J K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama; Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - D T Hsu
- Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, New York
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Aleksova N, Brahmbhatt DH, Kiamanesh O, Petropoulos JA, Chang Y, Guyatt G, Chih S, Ross HJ. The effect of antiplatelet therapy on survival and cardiac allograft vasculopathy following heart transplantation: A systematic review and meta-analysis. Clin Transplant 2020; 35:e14125. [PMID: 33068308 DOI: 10.1111/ctr.14125] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/18/2020] [Accepted: 10/10/2020] [Indexed: 11/29/2022]
Abstract
Cardiac allograft vasculopathy (CAV) is mediated by endothelial inflammation, platelet activation and thrombosis. Antiplatelet therapy may prevent the development of CAV. This systematic review and meta-analysis summarizes and appraises the evidence on the effect of antiplatelet therapy after heart transplantation (HT). CENTRAL(Ovid), MEDLINE(Ovid), Embase(Ovid) were searched from inception until April 30, 2020. Outcomes included CAV, all-cause mortality, and CAV-related mortality. Data were pooled using random-effects models. Seven observational studies including 2023 patients, mean age 52 years, 22% female, 47% with ischemic cardiomyopathy followed over a mean 7.1 years proved eligible. All studies compared acetylsalicylic acid (ASA) to no treatment and were at serious risk of bias. Data from 1911 patients in 6 studies were pooled in the meta-analyses. The evidence is very uncertain about the effect of ASA on all-cause or CAV-related mortality. ASA may reduce the development of CAV (RR 0.75, 95% CI: 0.44-1.29) based on very low certainty evidence. Two studies that conducted propensity-weighted analyses showed further reduction in CAV with ASA (HR 0.31, 95% CI: 0.13-0.74). In conclusion, there is limited evidence that ASA may reduce the development of CAV. Definitive resolution of the impact of antiplatelet therapy on CAV and mortality will require randomized clinical trials.
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Affiliation(s)
- Natasha Aleksova
- Ted Rogers Centre for Heart Research at the Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, ON, Canada
| | - Darshan H Brahmbhatt
- Ted Rogers Centre for Heart Research at the Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, ON, Canada.,National Heart & Lung Institute, Imperial College London, London, UK
| | - Omid Kiamanesh
- Ted Rogers Centre for Heart Research at the Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, ON, Canada.,Division of Cardiology, University of Calgary, Calgary, AB, Canada
| | | | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Sharon Chih
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Heather J Ross
- Ted Rogers Centre for Heart Research at the Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, ON, Canada
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Picão S, Oliveira-Santos M, Batista M, Prieto D, Antunes MJ, Pego M, Matos V, Gonçalves L, Jorge E. Cardiac allograft vasculopathy: Incidence and predictors in a single-center cohort. Rev Port Cardiol 2020; 39:205-212. [PMID: 32471665 DOI: 10.1016/j.repc.2019.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 10/08/2019] [Accepted: 10/27/2019] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION AND AIMS Cardiac allograft vasculopathy (CAV) is one of the most significant complications after orthotopic heart transplantation. We aimed to investigate the incidence and predictors of CAV in a large cohort of orthotopic heart transplantation patients. METHODS We conducted a retrospective analysis on a prospective cohort of 233 patients who underwent transplantation between November 2003 and May 2014. Baseline clinical data and invasive coronary angiograms (n=712) performed as part of the follow-up program were analyzed by two independent investigators. RESULTS We included 157 male and 45 female patients with a median age of 66 years. A third of patients had previous ischemic heart disease, 30% peripheral arterial disease, 37% hypertension and 47% dyslipidemia, and 17% were smokers. Acute moderate or severe rejection occurred in 42 patients during the first year. Over a median follow-up of 2920 days, 18% were diagnosed with CAV, with an incidence of 2.91 cases per 100 person-years. Predictors of CAV were previous ischemic heart disease (HR 2.32, 95% CI 1.21-4.45, p=0.01), carotid artery disease (HR 2.44, 95% CI 1.27-4.71, p<0.01), and donor age (HR 1.04, 95% CI 1.00-1.07, p=0.01). CONCLUSION In a single-center cohort of orthotopic heart transplantation patients, predictors of CAV were previous ischemic heart disease, carotid artery disease and donor age.
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Affiliation(s)
- Sofia Picão
- Centro Hospitalar da Universidade de Coimbra, Coimbra, Portugal.
| | | | - Manuel Batista
- Centro Hospitalar da Universidade de Coimbra, Coimbra, Portugal
| | - David Prieto
- Centro Hospitalar da Universidade de Coimbra, Coimbra, Portugal
| | | | - Mariano Pego
- Centro Hospitalar da Universidade de Coimbra, Coimbra, Portugal
| | - Vítor Matos
- Centro Hospitalar da Universidade de Coimbra, Coimbra, Portugal
| | - Lino Gonçalves
- Centro Hospitalar da Universidade de Coimbra, Coimbra, Portugal
| | - Elisabete Jorge
- Centro Hospitalar da Universidade de Coimbra, Coimbra, Portugal
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Das BB, Chan KC, Winchester RW, Zakrzewski M, Niu J. Correlation of gene expression profiling score, cardiac hemodynamics and echocardiographic parameters in asymptomatic, rejection-free pediatric heart transplant recipients. Pediatr Transplant 2020; 24:e13673. [PMID: 32067334 DOI: 10.1111/petr.13673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 01/21/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To correlate gene expression profiling scores obtained by AlloMap® with cardiac hemodynamics, cardiac allograft vasculopathy (CAV), and echocardiographic parameters in asymptomatic, rejection-free pediatric heart transplant (HT) recipients. METHODS Single-institution retrospective study of 210 AlloMap scores obtained concomitantly with cardiac catheterization and echocardiogram from 55 children during follow-up after cardiac transplantation. RESULTS The median age at HT was 5.1 years (range, 0.9-14.1), with 29 males and 26 females. AlloMap scores were high in <2 years vs ≥2 years of age at the time of HT (P = .001), and trending higher with time after HT (R2 = .04, P = .004). There was no significant difference in scores between ACR grades 0 and 1R or CAV. There was mild to modest correlation of AlloMap scores with the mean right atrial pressure (P = .002), and pulmonary capillary wedge pressure (P = .02), but no correlation was found with LV SF% (P = .3), LV EF% (P = .5), or RV FAC % (P = .8). CONCLUSIONS Our study provides preliminary data that the AlloMap score must be studied carefully before it can be used in children, particularly in those under 2 years of age. Monitoring of serial scores for each patient could potentially reflect changes in allograft performance that may determine indications for catheterization and biopsy which needs to be validated in future studies.
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Affiliation(s)
- Bibhuti B Das
- Pediatric Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, Florida.,Baylor College of Medicine, Texas Children's Hospital Austin Specialty Care, Austin, Texas
| | - Kak-Chen Chan
- Pediatric Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, Florida
| | - Robert W Winchester
- Pediatric Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, Florida
| | - Megan Zakrzewski
- Pediatric Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, Florida
| | - Jianli Niu
- Office of Human Research, Memorial Healthcare System, Hollywood, Florida
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5
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Picão S, Oliveira-Santos M, Batista M, Prieto D, Antunes MJ, Pego M, Matos V, Gonçalves L, Jorge E. Cardiac allograft vasculopathy: Incidence and predictors in a single-center cohort. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.repce.2019.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Abstract
Heart transplantation is offered to children with heart failure that is not amenable to medical or surgical therapy. Indications for heart transplant include unrepairable congenital heart disease, failed palliation of congenital heart disease, and cardiomyopathies. There has been tremendous progress in this field since the first heart transplant was performed in 1967. Each year, approximately 500 pediatric heart transplants take place worldwide. Pediatric heart transplant survivors are living longer with their initial transplant. Many pediatric practitioners are faced with caring for these patients before as well as after the heart transplant and, therefore, they should be knowledgeable about basic principles related to heart transplant. There are certain complications that are unique to this population, and medication side-effects, evaluation and management of a febrile illness, opportunistic infections, vaccination, pregnancy, and exercise recommendations are areas that require special consideration. [Pediatr Ann. 2018;47(4):e172-e178.].
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7
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Godown J, Harris MT, Burger J, Dodd DA. Variation in the use of surveillance endomyocardial biopsy among pediatric heart transplant centers over time. Pediatr Transplant 2015; 19:612-7. [PMID: 25943967 DOI: 10.1111/petr.12518] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2015] [Indexed: 11/28/2022]
Abstract
EMB is widely utilized for graft surveillance after HTx; however, there is significant variation in the frequency of surveillance EMB use during the first year post-HTx. The aim of this study was to assess changes in the utilization of surveillance EMB over time among member institutions of PHTS. A survey of PHTS centers assessing the frequency of surveillance EMB use during the first year post-HTx was conducted in 2006. The same survey was repeated in 2014 to assess changes in practice over time. The number of EMB in infants ranged from 0 to 9 and in adolescents 0 to 16. The number of EMB decreased or remained unchanged in the majority of centers. Fewer EMB are performed in infants compared to adolescents and this practice did not change over time. There was a significant decrease in surveillance EMB use in adolescents (p = 0.012). International centers perform significantly fewer EMB in adolescents when compared to centers within the United States (p = 0.006). There continues to be significant variation in the utilization of surveillance EMB, with a shift toward less reliance on EMB for adolescents in the current era. Further research is necessary to determine the optimal frequency of invasive monitoring that reduces costs without compromising outcomes.
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Affiliation(s)
- Justin Godown
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Michelle T Harris
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Judith Burger
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Debra A Dodd
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
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8
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Colvin MM, Cook JL, Chang P, Francis G, Hsu DT, Kiernan MS, Kobashigawa JA, Lindenfeld J, Masri SC, Miller D, O'Connell J, Rodriguez ER, Rosengard B, Self S, White-Williams C, Zeevi A. Antibody-mediated rejection in cardiac transplantation: emerging knowledge in diagnosis and management: a scientific statement from the American Heart Association. Circulation 2015; 131:1608-39. [PMID: 25838326 DOI: 10.1161/cir.0000000000000093] [Citation(s) in RCA: 225] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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9
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Harris KC, Manouzi A, Fung AY, De Souza A, Bezerra HG, Potts JE, Hosking MC. Feasibility of Optical Coherence Tomography in Children With Kawasaki Disease and Pediatric Heart Transplant Recipients. Circ Cardiovasc Imaging 2014; 7:671-8. [DOI: 10.1161/circimaging.113.001764] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Optical coherence tomography (OCT) is a high-resolution intravascular imaging technique used in adults. We tested the hypothesis that OCT could identify coronary abnormalities not seen by angiography in children with a history of Kawasaki disease (KD) and pediatric heart transplant (TX) recipients.
Methods and Results—
Patients with KD and TX recipients were evaluated between December 2012 and October 2013 with angiography and OCT (Ilumien System, LightLabs, St Jude Medical, Westford, MA). Modifications were made to the adult OCT protocol to adapt this technique for children. Serial cross-sectional area measurements of the lumen, intima, and media were made. Entire imaging data were analyzed for the presence of qualitative changes. Seventeen children were evaluated (5 patients with KD; 12 TX recipients). In patients with KD, angiography was normal. However, OCT imaging revealed that significant vessel wall abnormalities were present in all children including intimal thickening (intima/lumen cross-sectional area ratio>0.4), loss of the normal layered structure of the vessel wall, white thrombus, calcification, and neovascularization. There was extensive destruction of the internal elastic lamina. In TX recipients, angiography was normal; however, intimal thickening (intima/media cross-sectional area ratio>1) was seen in 9 of 12 patients. The median intima/media cross-sectional area ratio was 1.18.
Conclusions—
In this initial experience with OCT in children, we have identified significant coronary abnormalities with OCT that are angiographically silent in children with a history of coronary aneurysms because of KD and in pediatric TX recipients.
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Affiliation(s)
- Kevin C. Harris
- From the Division of Pediatric Cardiology, Department of Pediatrics (K.C.H., A.M., A.D.S., J.E.P., M.C.K.H.) and Division of Cardiology, Department of Medicine (A.Y.F.), University of British Columbia, Vancouver, Canada; and Division of Cardiology, Department of Medicine, Case Western Reserve University, Cleveland, OH (H.G.B.)
| | - Anas Manouzi
- From the Division of Pediatric Cardiology, Department of Pediatrics (K.C.H., A.M., A.D.S., J.E.P., M.C.K.H.) and Division of Cardiology, Department of Medicine (A.Y.F.), University of British Columbia, Vancouver, Canada; and Division of Cardiology, Department of Medicine, Case Western Reserve University, Cleveland, OH (H.G.B.)
| | - Anthony Y. Fung
- From the Division of Pediatric Cardiology, Department of Pediatrics (K.C.H., A.M., A.D.S., J.E.P., M.C.K.H.) and Division of Cardiology, Department of Medicine (A.Y.F.), University of British Columbia, Vancouver, Canada; and Division of Cardiology, Department of Medicine, Case Western Reserve University, Cleveland, OH (H.G.B.)
| | - Astrid De Souza
- From the Division of Pediatric Cardiology, Department of Pediatrics (K.C.H., A.M., A.D.S., J.E.P., M.C.K.H.) and Division of Cardiology, Department of Medicine (A.Y.F.), University of British Columbia, Vancouver, Canada; and Division of Cardiology, Department of Medicine, Case Western Reserve University, Cleveland, OH (H.G.B.)
| | - Hiram G. Bezerra
- From the Division of Pediatric Cardiology, Department of Pediatrics (K.C.H., A.M., A.D.S., J.E.P., M.C.K.H.) and Division of Cardiology, Department of Medicine (A.Y.F.), University of British Columbia, Vancouver, Canada; and Division of Cardiology, Department of Medicine, Case Western Reserve University, Cleveland, OH (H.G.B.)
| | - James E. Potts
- From the Division of Pediatric Cardiology, Department of Pediatrics (K.C.H., A.M., A.D.S., J.E.P., M.C.K.H.) and Division of Cardiology, Department of Medicine (A.Y.F.), University of British Columbia, Vancouver, Canada; and Division of Cardiology, Department of Medicine, Case Western Reserve University, Cleveland, OH (H.G.B.)
| | - Martin C.K. Hosking
- From the Division of Pediatric Cardiology, Department of Pediatrics (K.C.H., A.M., A.D.S., J.E.P., M.C.K.H.) and Division of Cardiology, Department of Medicine (A.Y.F.), University of British Columbia, Vancouver, Canada; and Division of Cardiology, Department of Medicine, Case Western Reserve University, Cleveland, OH (H.G.B.)
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Schumacher KR, Gajarski RJ, Urschel S. Pediatric Coronary Allograft Vasculopathy-A Review of Pathogenesis and Risk Factors. CONGENIT HEART DIS 2011; 7:312-23. [DOI: 10.1111/j.1747-0803.2011.00601.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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11
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Zheng Q, Liu S, Song Z. Mechanism of arterial remodeling in chronic allograft vasculopathy. Front Med 2011; 5:248-53. [DOI: 10.1007/s11684-011-0149-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 07/07/2011] [Indexed: 11/29/2022]
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12
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A role for antibodies to human leukocyte antigens, collagen-V, and K-α1-Tubulin in antibody-mediated rejection and cardiac allograft vasculopathy. Transplantation 2011; 91:1036-43. [PMID: 21383658 DOI: 10.1097/tp.0b013e318211d2f4] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We determined the role of donor-specific antibodies (DSA) and antibodies (Abs) to self-antigens, collagen-V (Col-V), and K-α1-Tubulin (KAT) in pathogenesis of acute antibody-mediated rejection (AMR) and cardiac allograft vasculopathy (CAV) after human heart transplantation (HTx). METHODS One hundred thirty-seven HTx recipients, with 60 early period (≤ 12 months) and 77 late period (>12 months), were enrolled in this study. Circulating DSA was determined using LUMINEX. Abs against Col-I, II, IV, V, and KAT were measured using ELISA. Frequency of CD4+T helper cells (CD4+Th) secreting interferon (IFN)-γ, interleukin (IL)-5, -10, or -17 specific to self-antigens were determined using Enzyme Linked Immunosorbent Spot assay. RESULTS A significant association between AMR and DSA was demonstrated. Development of DSA in AMR patients correlated well with the development of auto-Abs to Col-V (AMR[+]: 383 ± 72 μg/mL, AMR[-]: 172 ± 49 μg/mL, P=0.033) and KAT (AMR[+]: 252 ± 49 μg/mL, AMR[-]: 61 ± 21 μg/mL, P=0.014). Patients who developed AMR demonstrated increased frequencies of CD4+Th secreting IFN-γ and IL-5 with reduction in IL-10 specific for Col-V/KAT. Patients diagnosed with CAV also developed DSA and auto-Abs to Col-V (CAV[+]: 835 ± 142 μg/mL, CAV[-]: 242 ± 68 μg/mL, P=0.025) and KAT (CAV[+]: 768 ± 206 μg/mL, CAV[-]: 196 ± 72 μg/mL, P=0.001) with increased frequencies of CD4+Th secreting IL-17 with reduction in IL-10 specific for Col-V/KAT. CONCLUSIONS.: Development of Abs to human leukocyte antigens and self-antigens are associated with increases in CD4+Th secreting IFN-γ and IL-5 in AMR and IL-17 in CAV, with reduction in CD4+Th secreting IL-10 in both AMR and CAV.
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13
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Aiyagari R, Nika M, Gurney JG, Donohue JE, Zamberlan MC, King K, Crowley DC, Gajarski RJ. Association of Pediatric Heart Transplant Coronary Vasculopathy with Abnormal Hemodynamic Measures. CONGENIT HEART DIS 2011; 6:128-33. [DOI: 10.1111/j.1747-0803.2010.00470.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA, Madsen J, Parameshwar J, Starling RC, Uber PA. International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. J Heart Lung Transplant 2010; 29:717-27. [PMID: 20620917 DOI: 10.1016/j.healun.2010.05.017] [Citation(s) in RCA: 640] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Accepted: 05/22/2010] [Indexed: 01/14/2023] Open
Abstract
The development of cardiac allograft vasculopathy remains the Achilles heel of cardiac transplantation. Unfortunately, the definitions of cardiac allograft vasculopathy are diverse, and there are no uniform international standards for the nomenclature of this entity. This consensus document, commissioned by the International Society of Heart and Lung Transplantation Board, is based on best evidence and clinical consensus derived from critical analysis of available information pertaining to angiography, intravascular ultrasound imaging, microvascular function, cardiac allograft histology, circulating immune markers, non-invasive imaging tests, and gene-based and protein-based biomarkers. This document represents a working formulation for an international nomenclature of cardiac allograft vasculopathy, similar to the development of the system for adjudication of cardiac allograft rejection by histology.
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Affiliation(s)
- Mandeep R Mehra
- ISHLT Working Group on Classification of Cardiac Allograft Vasculopathy commissioned by the Education Committee and Board of Directors of the Society.
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15
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Christen T, Shimizu K, Libby P. Advances in Imaging of Cardiac Allograft Rejection. CURRENT CARDIOVASCULAR IMAGING REPORTS 2010. [DOI: 10.1007/s12410-010-9011-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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16
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Morrow WR. Outcomes following heart transplantation in children. PROGRESS IN PEDIATRIC CARDIOLOGY 2009. [DOI: 10.1016/j.ppedcard.2008.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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17
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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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Hedman M, Pahlman R, Sundvall J, Ehnholm C, Syvänne M, Jokinen E, Jauhiainen M, Holmberg C, Antikainen M. Low HDL-C predicts the onset of transplant vasculopathy in pediatric cardiac recipients on pravastatin therapy. Pediatr Transplant 2007; 11:481-90. [PMID: 17631015 DOI: 10.1111/j.1399-3046.2007.00690.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The levels and protein/lipid compositions of major lipoprotein particles of 19 pediatric cardiac transplant recipients (4-18 yr of age) were studied in this prospective, open clinical follow-up study before and at one yr of pravastatin therapy (10 mg/day). The recipients were grouped into those with (n = 6; group A) and those without (n = 13; group B) angiographically detectable vasculopathy. Twenty-one pediatric non-transplant controls were studied at baseline. At baseline, the group A recipients had 29% lower HDL-C concentrations (p = 0.031) and 29% higher apoB-100/apoA-I ratios (p = 0.034) than the group B recipients. At one yr of pravastatin, the respective figures were 29% (p = 0.013) and 33% (p = 0.005). Compared with the healthy pediatric controls, the transplant recipients had significantly higher serum TG before pravastatin [median (range): 1.3 mmol/L (0.6-3.2) vs. 0.7 mmol/L (0.3-2.4), p = 0.0002] and at one yr [1.3 mmol/L (0.5-3.5) vs. 0.7 mmol/L (0.3-2.4), p = 0.0004]. The baseline apoB-100/apoA1 ratios of the recipients were 33% higher (p = 0.005). In conclusion, low HDL-C and high apoB-100/apoA-I ratio were associated with angiographically detectable vasculopathy. Even though pravastatin effectively lowered the TC and LDL-C and improved compositional properties of LDL and HDL(2) particles, it failed to normalize the elevated TG and, in some patients, to prevent the progression of transplant vasculopathy.
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Affiliation(s)
- Mia Hedman
- Hospital for Children and Adolescents, University of Helsinki, FIN-00029 HUS, Helsinki, Finland
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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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Abstract
During the past two decades, several advances have resulted in marked improvement in medium-term survival for infants and children undergoing heart transplantation. Unfortunately, progress has been less dramatic in the field of lung and heart-lung transplantation, where there is little evidence of improved outcomes. The procedures remain palliative and all transplant recipients are at risk for the adverse effects of non-specific immunosuppression, including infections, lymphoproliferative disorders, and non-lymphoid malignancies. In addition, current immunosuppressive agents have narrow therapeutic windows and exhibit a wide array of organ toxicities, posing special challenges for the young patient who must endure life-long immunosuppression. New immunosuppressive regimens have lowered the rates of acute rejection but appear to have had relatively little impact on the incidence of chronic rejection, the principal cause of late graft loss. The ultimate goal is to induce a state of donor-specific tolerance, wherein the recipient will accept the allograft indefinitely without the need for long-term immunosuppression. This quest is currently being realised in animal models of solid organ transplantation, and offers great hope for children undergoing heart and lung transplantation in the future.
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Affiliation(s)
- Steven A Webber
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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