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Watanabe K, Arva NC, Robinson JD, Rigsby C, Markl M, Sojka M, Tannous P, Arzu J, Husain N. Cardiac magnetic resonance imaging in detection of progressive graft dysfunction in pediatric heart transplantation. Pediatr Transplant 2024; 28:e14652. [PMID: 38063266 PMCID: PMC10872936 DOI: 10.1111/petr.14652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/01/2023] [Accepted: 11/04/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Chronic graft failure (CGF) in pediatric heart transplant (PHT) is multifactorial and may present with findings of fibrosis and microvessel disease (MVD) on endomyocardial biopsy (EMB). There is no optimal CGF surveillance method. We evaluated associations between cardiac magnetic resonance imaging (CMR) and historical/EMB correlates of CGF to assess CMR's utility as a surveillance method. METHODS Retrospective analysis of PHT undergoing comprehensive CMR between September 2015 and January 2022 was performed. EMB within 6 months was graded for fibrosis (scale 0-5) and MVD (number of capillaries with stenotic wall thickening per field of view). Correlation analysis and logistic regression were performed. RESULTS Forty-seven PHT with median age at CMR of 15.7 years (11.6, 19.3) and time from transplant of 6.4 years (4.1, 11.0) were studied. Cardiac allograft vasculopathy (CAV) was present in 11/44 (22.0%) and historical rejection in 14/41 (34.2%). CAV was associated with higher global T2 (49.0 vs. 47.0 ms; p = 0.038) and peak T2 (57.0 vs. 53.0 ms; p = 0.013) on CMR. Historical rejection was associated with higher global T2 (49.0 vs. 47.0 ms; p = 0.007) and peak T2 (57.0 vs. 53.0 ms; p = 0.03) as well as global extracellular volume (31.0 vs. 26.3%; p = 0.03). Higher fibrosis score on EMB correlated with smaller indexed left ventricular mass (rho = -0.34; p = 0.019) and greater degree of MVD with lower indexed left ventricular end-diastolic volume (rho = -0.35; p = 0.017). CONCLUSION Adverse ventricular remodeling and abnormal myocardial characteristics on CMR are present in PHT with CAV, historical rejection, as well as greater fibrosis and MVD on EMB. CMR has the potential use for screening of CGF.
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Affiliation(s)
- Kae Watanabe
- Lille Frank Abercrombie Section of Cardiology, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Nicoleta C. Arva
- Department of Pathology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Joshua D. Robinson
- Division of Pediatric Cardiology, Ann & Robert H Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Cynthia Rigsby
- Division of Pediatric Radiology, Ann & Robert H Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Michael Markl
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Melanie Sojka
- Division of Pediatric Cardiology, Ann & Robert H Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Paul Tannous
- Division of Pediatric Cardiology, Ann & Robert H Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Jennifer Arzu
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Nazia Husain
- Division of Pediatric Cardiology, Ann & Robert H Lurie Children’s Hospital of Chicago, Chicago, IL
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Marco I, López-Azor García JC, González Martín J, Severo Sánchez A, García-Cosío Carmena MD, Mancebo Sierra E, de Juan Bagudá J, Castrodeza Calvo J, Hernández Pérez FJ, Delgado JF. De Novo Donor-Specific Antibodies after Heart Transplantation: A Comprehensive Guide for Clinicians. J Clin Med 2023; 12:7474. [PMID: 38068526 PMCID: PMC10707043 DOI: 10.3390/jcm12237474] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 04/12/2024] Open
Abstract
Antibodies directed against donor-specific human leukocyte antigens (HLAs) can be detected de novo after heart transplantation and play a key role in long-term survival. De novo donor-specific antibodies (dnDSAs) have been associated with cardiac allograft vasculopathy, antibody-mediated rejection, and mortality. Advances in detection methods and international guideline recommendations have encouraged the adoption of screening protocols among heart transplant units. However, there is still a lack of consensus about the correct course of action after dnDSA detection. Treatment is usually started when antibody-mediated rejection is present; however, some dnDSAs appear years before graft failure is detected, and at this point, damage may be irreversible. In particular, class II, anti-HLA-DQ, complement binding, and persistent dnDSAs have been associated with worse outcomes. Growing evidence points towards a more aggressive management of dnDSA. For that purpose, better diagnostic tools are needed in order to identify subclinical graft injury. Cardiac magnetic resonance, strain techniques, or coronary physiology parameters could provide valuable information to identify patients at risk. Treatment of dnDSA usually involves plasmapheresis, intravenous immunoglobulin, immunoadsorption, and ritxumab, but the benefit of these therapies is still controversial. Future efforts should focus on establishing effective treatment protocols in order to improve long-term survival of heart transplant recipients.
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Affiliation(s)
- Irene Marco
- Cardiology Department, Hospital Universitario La Paz, 28046 Madrid, Spain;
| | - Juan Carlos López-Azor García
- Cardiology Department, Hospital Universitario Puerta de Hierro, 28222 Madrid, Spain; (J.C.L.-A.G.); (F.J.H.P.)
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- School of Medicine, Universidad Europea de Madrid, 28670 Madrid, Spain
| | - Javier González Martín
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Andrea Severo Sánchez
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - María Dolores García-Cosío Carmena
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Esther Mancebo Sierra
- Immunology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Javier de Juan Bagudá
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- School of Medicine, Universidad Europea de Madrid, 28670 Madrid, Spain
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Javier Castrodeza Calvo
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario Gregorio Marañón, 28007 Madrid, Spain
| | | | - Juan Francisco Delgado
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
- School of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
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Watanabe K, Husain N, Arzu JL, Wechsler JB, Arva NC. Increased fibrosis and microvessel disease in allograft endomyocardial biopsies of children with chronic graft failure due to cardiac allograft vasculopathy. Cardiovasc Pathol 2023; 63:107509. [PMID: 36442702 DOI: 10.1016/j.carpath.2022.107509] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 11/11/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Chronic graft failure (CGF) is the leading cause of mortality in pediatric heart transplant (PHT) patients and has multifactorial pathogenesis including cardiac allograft vasculopathy (CAV). CGF can present with microvessel disease (MVD) and myocardial fibrosis on endomyocardial biopsies (EMB). We investigated if CGF due to moderate- severe (M-S) CAV has histopathologic MVD and fibrosis prior to or at the time of CAV diagnosis. METHOD This retrospective case-control study included PHT with CGF secondary to M-S CAV. Control patients had no CAV or CGF. EMBs from CAV (3 sets: at 1-year post-transplant 1yrCAV, pre-CAV, and at the time of CAV diagnosis) and non-CAV cohorts were reviewed to grade the fibrosis and quantify MVD. Histopathologic changes were correlated and compared between CAV/non-CAV groups. RESULTS Each group had 8 patients. The median age at transplantation and time since transplant were similar between the two groups (P=.71 and P=.91, respectively). Fibrosis grade was 3.0 for CAV cohort compared to 1.0 for control (P= .003) and MVD score was 2.1 in CAV and 0.5 in non-CAV patients (P=.003). Similar degrees of fibrosis and MVD were present even before any evidence of CAV (1yrCAV fibrosis grade 2.5, pre-CAV fibrosis grade 2; 1yrCAV vs CAV P=.75, pre-CAV vs CAV P=.63; 1yrCAV MVD score 2, pre-CAV MVD score 2; 1yrCAV vs CAV P=1, pre-CAV vs CAV P=.91). The degree of MVD correlated with fibrosis (r=0.63, P<.0001) for all EMBs. CONCLUSION Simultaneous myocardial fibrosis and MVD are noted in CGF secondary to M-S CAV, changes that occur before angiographic CAV. EMBs can reveal significant changes in patients with subsequent development of CAV and may be used to modify the follow-up and treatment for these high-risk patients.
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Affiliation(s)
- Kae Watanabe
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nazia Husain
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jennifer L Arzu
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joshua B Wechsler
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nicoleta C Arva
- Department of Pathology, Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Irion CI, Dunkley JC, John-Williams K, Condor Capcha JM, Shehadeh SA, Pinto A, Loebe M, Webster KA, Brozzi NA, Shehadeh LA. Nuclear Osteopontin Is a Marker of Advanced Heart Failure and Cardiac Allograft Vasculopathy: Evidence From Transplant and Retransplant Hearts. Front Physiol 2020; 11:928. [PMID: 32903540 PMCID: PMC7438570 DOI: 10.3389/fphys.2020.00928] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/10/2020] [Indexed: 12/22/2022] Open
Abstract
Background Heart transplant is the gold standard therapy for patients with advanced heart failure. Over 5,500 heart transplants are performed every year worldwide. Cardiac allograft vasculopathy (CAV) is a common complication post-heart transplant which reduces survival and often necessitates heart retransplantation. Post-transplant follow-up requires serial coronary angiography and endomyocardial biopsy (EMB) for CAV and allograft rejection screening, respectively; both of which are invasive procedures. This study aims to determine whether osteopontin (OPN) protein, a fibrosis marker often present in chronic heart disease, represents a novel biomarker for CAV. Methods Expression of OPN was analyzed in cardiac tissue obtained from patients undergoing heart retransplantation using immunofluorescence imaging (n = 20). Tissues from native explanted hearts and three serial follow-up EMB samples of transplanted hearts were also analyzed in five of these patients. Results Fifteen out of 20 patients undergoing retransplantation had CAV. 13/15 patients with CAV expressed nuclear OPN. 5/5 patients with multiple tissue samples expressed nuclear OPN in both 1st and 2nd explanted hearts, while 0/5 expressed nuclear OPN in any of the follow-up EMBs. 4/5 of these patients had an initial diagnosis of dilated cardiomyopathy (DCM). Conclusion Nuclear localization of OPN in cardiomyocytes of patients with CAV was evident at the time of cardiac retransplant as well as in patients with DCM at the time of the 1st transplant. The results implicate nuclear OPN as a novel biomarker for severe CAV and DCM.
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Affiliation(s)
- Camila Iansen Irion
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States.,Division of Cardiology, Department of Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| | - Julian C Dunkley
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States.,Division of Cardiology, Department of Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| | - Krista John-Williams
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States.,Division of Cardiology, Department of Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| | - José Manuel Condor Capcha
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States.,Division of Cardiology, Department of Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| | - Serene A Shehadeh
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| | - Andre Pinto
- Department of Pathology, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| | - Matthias Loebe
- Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| | - Keith A Webster
- Vascular Biology Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| | - Nicolas A Brozzi
- Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| | - Lina A Shehadeh
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States.,Division of Cardiology, Department of Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States.,Vascular Biology Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States.,Peggy and Harold Katz Family Drug Discovery Center, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
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5
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Abstract
The assessment of pediatric patients after orthotropic heart transplantation (OHT) relies heavily on non-invasive imaging. Because of the potential risks associated with cardiac catheterization, expanding the role of non-invasive imaging is appealing. Echocardiography is fast, widely available, and can provide an accurate assessment of chamber sizes and function. Advanced echocardiographic methods, such as myocardial deformation, have potential to assess for acute rejection or cardiac allograft vasculopathy (CAV). While not currently part of routine care, cardiac magnetic resonance imaging (CMR) and computed tomography may potentially aid in the detection of graft complications following OHT. In particular, CMR tissue characterization holds promise for diagnosing rejection, while quantitative perfusion and myocardial late gadolinium enhancement may have a role in the detection of CAV. This review will evaluate standard and novel methods for non-invasive assessment of pediatric patients after OHT.
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Affiliation(s)
- Jonathan H Soslow
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Margaret M Samyn
- Medical College of Wisconsin, Pediatrics (Cardiology), Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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6
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The Effect of Obstructive Sleep Apnea on 3-Year Outcomes in Patients Who Underwent Orthotopic Heart Transplantation. Am J Cardiol 2019; 124:51-54. [PMID: 31029415 DOI: 10.1016/j.amjcard.2019.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/22/2019] [Accepted: 04/01/2019] [Indexed: 12/14/2022]
Abstract
Despite the well-known association between obstructive sleep apnea (OSA) and cardiovascular disease, there is a paucity of data regarding OSA in orthotopic heart transplant (OHT) recipients and its effect on clinical outcomes. Hence, we sought to determine the association between OSA, as detected by polysomnography, and late graft dysfunction (LGD) after OHT. In this retrospective review of consecutive OHT recipients from 2012 to 2014 at our center, we examined LGD, i.e., graft failure >1 year after OHT, through competing risks analysis. Due to small sample size and event counts, as well as preliminary testing which revealed statistically similar demographics and outcomes, we pooled patients who had treated OSA with those who had no OSA. Of 146 patients, 29 (20%) had untreated OSA, i.e., OSA without use of continuous positive airway pressure therapy, at the time of transplantation. Patients with untreated OSA were significantly older, heavier, and more likely to have baseline hypertension than those with treated/no OSA. Although there were no differences between groups in regard to short-term complications of acute kidney injury, cardiac allograft vasculopathy, or primary graft dysfunction, there were significant differences in the occurrence of LGD. Those with untreated OSA were at 3 times the risk of developing LGD than those with treated/no OSA (hazard ratio 3.2; 95% confidence interval 1.3 to 7.9; p = 0.01). Because OSA is a common co-morbidity of OHT patients and because patients with untreated OSA have an elevated risk of LGD, screening for and treating OSA should occur during the OHT selection period.
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López-Sainz Á, Barge-Caballero E, Barge-Caballero G, Couto-Mallón D, Paniagua-Martin MJ, Seoane-Quiroga L, Iglesias-Gil C, Herrera-Noreña JM, Cuenca-Castillo JJ, Vázquez-Rodríguez JM, Crespo-Leiro MG. Late graft failure in heart transplant recipients: incidence, risk factors and clinical outcomes. Eur J Heart Fail 2017; 20:385-394. [DOI: 10.1002/ejhf.886] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 03/27/2017] [Accepted: 04/12/2017] [Indexed: 11/10/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Carmen Iglesias-Gil
- Servicio de Cirugía Cardiaca; Complexo Hospitalario Universitario de A Coruña (CHUAC), Servicio Galego de Saúde (SERGAS), Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidad de A Coruña (UDC), Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV); La Coruna Spain
| | - José M. Herrera-Noreña
- Servicio de Cirugía Cardiaca; Complexo Hospitalario Universitario de A Coruña (CHUAC), Servicio Galego de Saúde (SERGAS), Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidad de A Coruña (UDC), Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV); La Coruna Spain
| | - José J. Cuenca-Castillo
- Servicio de Cirugía Cardiaca; Complexo Hospitalario Universitario de A Coruña (CHUAC), Servicio Galego de Saúde (SERGAS), Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidad de A Coruña (UDC), Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV); La Coruna Spain
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8
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Chronic heart failure in heart transplant recipients: Presenting features and outcome. Arch Cardiovasc Dis 2016; 109:254-9. [DOI: 10.1016/j.acvd.2016.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 12/24/2015] [Accepted: 01/13/2016] [Indexed: 01/01/2023]
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9
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Reid AB, Waldron N, Schmitt M, Miller CA. The Value of Cardiovascular Magnetic Resonance in Heart Transplant Patients. Curr Cardiol Rep 2015; 17:612. [PMID: 26055963 DOI: 10.1007/s11886-015-0612-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Heart transplant patients present a unique set of anatomical and pathophysiological considerations. Patients often present non-specifically, requiring a low index for further investigation. Accurate assessment with standard imaging modalities can be difficult, and cardiovascular magnetic resonance (CMR) is becoming an increasingly useful modality in the assessment of heart transplant patients. This review describes the anatomy of the transplanted heart and typical CMR appearances and discusses the role of CMR in heart transplant disease.
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Affiliation(s)
- Anna B Reid
- North West Heart Centre, University Hospital of South Manchester, Wythenshawe, Manchester, UK,
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10
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Race and ethnic differences in the epidemiology and risk factors for graft failure after heart transplantation. J Heart Lung Transplant 2015; 34:825-31. [DOI: 10.1016/j.healun.2014.12.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 11/21/2014] [Accepted: 12/17/2014] [Indexed: 11/23/2022] Open
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Koerner MM, Ghodsizad A, Schulz U, El Banayosy A, Koerfer R, Tenderich G. Normothermic Ex Vivo Allograft Blood Perfusion in Clinical Heart Transplantation. Heart Surg Forum 2014; 17:E141-5. [DOI: 10.1532/hsf98.2014332] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
<p><b>Background:</b> Cold ischemia associated with cold static storage is an independent risk factor for primary allograft failure and survival of patients after orthotopic heart transplantation. The effects of normothermic ex vivo allograft blood perfusion on outcomes after orthotopic heart transplantation compared to cold static storage have been studied.</p><p><b>Methods:</b> In this prospective, nonrandomized, single-institutional clinical study, normothermic ex vivo allograft blood perfusion has been performed using an organ care system (OCS) (TransMedics, Andover, MA, USA). Included were consecutive adult transplantation patients who received an orthotopic heart transplantation (oHTx) without a history of any organ transplantation, in the absence of a congenital heart disorder as an underlying disease and not being in need of a combined heart-lung transplantation. Furthermore, patients with fixed pulmonary hypertension, ventilator dependency, chronic renal failure, or panel reactive antibodies >20% and positive T-cell cross-matching were excluded. Inclusion criteria for donor hearts was age of <55 years, systolic blood pressure >85 mmHg at the time of final heart assessment under moderate inotropic support, heart rate of <120 bpm at the time of explantation, and left ventricular ejection fraction >40% assessed by an transcutaneous echo/Doppler study with the absence of gross wall motion abnormalities, absence of left ventricular hypertrophy, and absence of valve abnormalities. Donor hearts which were conventionally cold stored with histidine-tryptophan-ketoglutarate solution (Custodiol; Koehler Chemie, Ansbach, Germany) constituted the control group. The primary end point was the recipients' survival at 30 days and 1 and 2 years after their heart transplantation. Secondary end points were primary and chronic allograft failure, noncardiac complications, and length of hospital stay.</p><p><b>Results:</b> Over a 2-year period (January 2006 to July 2008), 159 adult cardiac allografts were transplanted. Twenty-nine were assigned for normothermic ex vivo allograft blood perfusion and 130 for cold static storage with HTK solution. Cumulative survival rates at 30 days and 1 and 2 years were 96%, 89%, and 89%, respectively, whereas in the cold static storage group survival after oHTx was 95%, 81%, and 79%. Primary graft failure was less frequent in the recipients of an oHTx who received a donor heart which had been preserved with normothermic ex vivo allograft blood perfusion using an OCS (6.89% versus 15.3%; <i>P</i> = .20). Episodes of severe acute rejection (23% versus 17.2%; <i>P</i> = .73), as well as, cases of acute renal failure requiring haemodialysis (25.3% versus 10%; <i>P</i> = .05) were more frequent diagnosed among recipients of a donor heart which had been preserved using the cold static storage. The length of hospital stay did not differ (26 days versus 28 days; <i>P</i> = .80) in both groups.</p><p><b>Conclusions:</b> Normothermic ex vivo allograft blood perfusion in adult clinical orthotopic heart transplantation contributes to better outcomes after transplantation in regard to recipient survival, incidence of primary graft dysfunction, and incidence of acute rejection.</p>
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12
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Aquilante CL, Page RL, Vu A, Roscoe N, Wolfel EE, Lindenfeld JA. Comparison of office, home, and ambulatory blood pressure in heart transplant recipients. J Card Fail 2014; 20:602-10. [PMID: 24858056 DOI: 10.1016/j.cardfail.2014.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 05/08/2014] [Accepted: 05/14/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The purpose of this study was to prospectively evaluate the relationship between office, home, and ambulatory blood pressure (BP) in heart transplant recipients. METHODS AND RESULTS The study enrolled 30 adults ≥ 6 months after heart transplantation. Morning seated office BP was measured with the use of an automatic device at 3 outpatient visits. Seated home BP was measured in the morning and evening for 5 consecutive days. Ambulatory BP was measured over 24 hours with the use of a Spacelabs monitor. The strongest correlation was observed between home and 24-hour ambulatory BP (r = 0.79 systolic; r = 0.72 diastolic). Office and home systolic BPs were significantly lower than daytime ambulatory BP (office, -3.7 mm Hg, P = .009; home, -2.6 mm Hg, P = .05). Ambulatory monitoring identified more participants with BP above hypertensive limits than did office or home measurements (63%, 50%, and 13%, respectively; P = .003). Ambulatory monitoring also revealed high BP loads, abnormal nocturnal BP patterns (eg, 30% nondippers), and a high percentage of masked hypertension (37% home, 50% ambulatory). CONCLUSIONS Office and home BP monitoring are acceptable but may underestimate BP burden in heart transplant recipients. Additional studies are needed to determine which BP method is superior for the management of hypertension and associated outcomes after heart transplantation.
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Affiliation(s)
- Christina L Aquilante
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado.
| | - Robert L Page
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Anh Vu
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Nicholai Roscoe
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Eugene E Wolfel
- Division of Cardiology, School of Medicine, University of Colorado, Aurora, Colorado
| | - JoAnn A Lindenfeld
- Division of Cardiology, School of Medicine, University of Colorado, Aurora, Colorado
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13
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Abstract
There is a striking consistency in the total number of heart beats accrued over a lifetime across a range of animal species despite vast differences in size. Moreover, an inverse relationship is observed between heart rate and lifespan, leading to speculation that elevated heart rate could significantly affect longevity. It is the aim of this review to analyze heart rate as a contributing factor in defining the functional lifespan of the transplanted human heart, which may unavoidably determine the longevity of the recipient. Sinus tachycardia occurs as a result of sympathetic/parasympathetic denervation, an unavoidable consequence of transplantation. The effect of elevated heart rate in this cohort has been scarcely reported. We highlight herein multitudinous mechanisms whereby elevated heart rate accelerates the deterioration in cardiac function and arterial elasticity due to injury and stress accumulation. Additionally, we propose a significant role for heart rate in confounding the alloimmune response. Tachycardia exacerbates injurious episodes of myocardial ischemia and significantly increases the production of reactive oxygen species via increased metabolism. These factors promote immune infiltration and activation, contributing to acute and chronic rejection. Further research is required to assess the potential therapeutic benefits of heart rate reduction.
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Lourenço-Filho DD, Maranhão RC, Méndez-Contreras CA, Tavares ER, Freitas FR, Stolf NA. An artificial nanoemulsion carrying paclitaxel decreases the transplant heart vascular disease: A study in a rabbit graft model. J Thorac Cardiovasc Surg 2011; 141:1522-8. [DOI: 10.1016/j.jtcvs.2010.08.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 07/14/2010] [Accepted: 08/08/2010] [Indexed: 10/18/2022]
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15
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Marques MB, Schwartz J. Update on extracorporeal photopheresis in heart and lung transplantation. J Clin Apher 2010; 26:146-51. [DOI: 10.1002/jca.20274] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 10/12/2010] [Indexed: 12/18/2022]
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16
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Flow cessation triggers endothelial dysfunction during organ cold storage conditions: strategies for pharmacologic intervention. Transplantation 2010; 90:142-9. [PMID: 20606606 DOI: 10.1097/tp.0b013e3181e228db] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Vascular pathologies constitute a major cause of graft rejection after organ transplantation. Recent studies have documented an improvement in transplant outcome when organs are preserved through pulsatile perfusion; however, the underlying mechanisms of these observations are poorly characterized. We hypothesized that the temporary absence of flow occurring in the context of organ cold storage conditions disrupts endothelial vasoprotective programs, and that this consequence of stasis may be a target for pharmacological modulation. METHODS The expression of the transcription factor Kruppel-like factor 2 (KLF2) and its vasoprotective target genes were assessed during cold storage conditions in cultured human endothelial cells and murine aortic segments. In addition, we evaluated the effect of simvastatin used as a supplement in a cold preservation solution on the expression of vasoprotective genes, and on endothelial activation and apoptosis. RESULTS The expression of endothelial KLF2 and its vasoprotective transcriptional targets were rapidly lost during cold preservation in vitro and ex vivo. Importantly, simvastatin treatment blocked the decay of KLF2, sustaining a vasoprotective phenotype, and preventing endothelial activation and apoptosis. CONCLUSIONS Flow stasis leads to acute endothelial dysfunction and apoptosis in the context of cold storage conditions. Supplementation of organ preservation solutions with pharmacologic agents that restore endothelial vasoprotective programs, by upregulating KLF2, may represent a significant advancement of current organ preservation techniques.
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Mariani JA, McDonald MA, Nanthakumar K, Parker JD, Ross HJ. Cardiac resynchronization therapy after atrioventricular node ablation for rapid atrial fibrillation in a heart transplant recipient with late allograft dysfunction. J Heart Lung Transplant 2010; 29:704-6. [DOI: 10.1016/j.healun.2010.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Revised: 01/08/2010] [Accepted: 01/17/2010] [Indexed: 11/30/2022] Open
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18
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Najam O, Yonan N, Williams SG, Shaw SM. The usefulness of chronic heart failure treatments in chronic cardiac graft failure. Cardiovasc Ther 2010; 28:48-58. [PMID: 20074259 DOI: 10.1111/j.1755-5922.2009.00125.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Following cardiac transplantation, registry data has demonstrated a gradual improvement in survival over the last several decades, which is testament to continual improvement in aftercare strategy. However, a significant number of patients will eventually develop a new syndrome of chronic heart failure, owing to the multitude of physiological processes that occur after transplantation. This condition, referred to as chronic graft failure (CGF) should be regarded as a unique illness rather than one that is simply analogous with chronic heart failure. In particular, the unique pathophysiological (and pharmacological) environment in the setting of CGF presents a challenging situation to the transplant physician. There is uncertainty over which treatments to offer given a paucity of clinical trial data to support the use of standard heart failure treatments in CGF. In this review, we discuss which chronic heart failure treatments could be considered in the setting of CGF based on their mechanisms of action, benefits within the native heart failure setting, and the relevant issues within the posttransplant environment.
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Affiliation(s)
- Osman Najam
- North West Regional Heart Centre and Transplant Unit, University of South Manchester NHS Foundation Trust, Wythenshawe Hospital, Manchester M23 9LT, UK
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