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Youn JC, Kim D, Jung MH, Kim JJ, Kim IC, Lee HS, Choi JO, Jeon ES, Nishihara K, Seguchi O, Kransdorf EP, Chang DH, Kittleson MM, Patel JK, Cole RM, Moriguchi JD, Ramzy D, Esmailian F, Kobashigawa JA. Three year post heart transplant outcomes of desensitized durable mechanical circulatory support patients. J Heart Lung Transplant 2023; 42:1408-1414. [PMID: 37150473 DOI: 10.1016/j.healun.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 04/16/2023] [Accepted: 05/02/2023] [Indexed: 05/09/2023] Open
Abstract
BACKGROUND The risks and benefits of desensitization therapy (DST) in highly sensitized mechanical circulatory support (MCS) patients are not well known. We investigated 3 year post-transplant outcomes of desensitized durable MCS patients. METHODS Among 689 consecutively enrolled heart transplantation recipients between 2010 and 2016, we categorized them into Group A (desensitized MCS patients, n = 21), Group B (desensitized non-MCS patients, n = 28) and Group C (all nondesensitized patients, n = 640). Post-transplant outcomes included the incidence of primary graft dysfunction, 3-year survival, freedom from cardiac allograft vasculopathy, nonfatal major adverse cardiac events, any treated rejection, acute cellular rejection, antibody mediated rejection (AMR) and infectious complications. RESULTS The types of DST in Groups A and B were similar and included combinations of rituximab/intravenous immunoglobulin and plasmapheresis/bortezomib. Group A, compared with Group B, showed significantly higher pre-DST panel reactive antibody (PRA) (92.2 ± 9.8 vs. 83.3 ± 15.6, P = 0.007) and higher PRA reduction after DST (-22.2 ± 26.9 vs. -6.3 ± 7.5, P = 0.015). Groups A and C showed comparable primary graft dysfunction, 3-year survival, freedom from cardiac allograft vasculopathy, nonfatal major adverse cardiac events, any treated rejection, acute cellular rejection, and AMR. Although statistically not significant, Group A showed numerically higher 3-year freedom from AMR than Group B. Infectious complications were similar in both Groups A and B. CONCLUSIONS DST for MCS patients showed significant PRA reduction, resulting in an expansion of the donor pool. The post-transplant outcome of desensitized MCS patients showed comparable clinical outcomes to non-desensitized control patients in the same study period, revealing the safety and efficacy of DST.
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Affiliation(s)
- Jong-Chan Youn
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Darae Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Mi-Hyang Jung
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin-Jin Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - In-Cheol Kim
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun-Seok Jeon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Keith Nishihara
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Osamu Seguchi
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Evan P Kransdorf
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David H Chang
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jignesh K Patel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Robert M Cole
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jaime D Moriguchi
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Danny Ramzy
- Department of Cardiothoracic Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Fardad Esmailian
- Department of Cardiothoracic Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Rodriguez ER, Santos-Martins C, Tan CD. Pathology of cardiac transplantation. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00023-2] [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: 10/17/2022] Open
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Post-transplantation outcomes of sensitized patients receiving durable mechanical circulatory support. J Heart Lung Transplant 2021; 41:365-372. [PMID: 34895990 DOI: 10.1016/j.healun.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 09/14/2021] [Accepted: 11/11/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Sensitization, defined as the presence of circulating antibodies, presents challenges, particularly in patients undergoing heart transplantation (HTx) bridged with durable mechanical circulatory support (MCS). We aimed to investigate the post-transplantation outcomes of sensitized MCS patients. METHODS Among 889 consecutively enrolled heart transplant (HTx) recipients between 2010 and 2018, 86 (9.7%) sensitized MCS patients (Group A) were compared with sensitized non-MCS patients (Group B, n = 189), non-sensitized MCS patients (Group C, n = 162), and non-sensitized non-MCS patients (Group D, n = 452) regarding post-HTx outcomes, including the incidence of primary graft dysfunction (PGD), 1-year survival, and 1-year freedom from antibody-mediated rejection (AMR). RESULTS Sensitized MCS patients (Group A) showed comparable rates of PGD, 1-year survival, and 1-year freedom from AMR with Groups C and D. However, Group A showed significantly higher rates of 1-year freedom from AMR (95.3% vs 85.7%, p = 0.02) and an earlier decline in panel-reactive antibody (PRA) levels (p < 0.01) than sensitized non-MCS patients (Group B). Desensitization therapy effectively reduced the levels of PRA in both Groups A and B. When Group A was further divided according to the presence of preformed donor-specific antibodies (DSA), patients with preformed DSA showed significantly lower rates of 1-year freedom from AMR than those without (84.2% vs 98.5%, p = 0.01). CONCLUSIONS Sensitized MCS patients showed significantly lower rates of AMR and an earlier decline in PRA levels following HTx than sensitized non-MCS patients. Removal of MCS at the time of transplantation might underlie these observations.
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Patel JK, Kittleson MM. The challenge of heart transplantation in sensitized patients-carfilzomib and the importance of shared experience. J Heart Lung Transplant 2021; 40:604-606. [PMID: 33896695 DOI: 10.1016/j.healun.2021.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- Jignesh K Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Cotter TG, Wang J, Peeraphatdit T, Sandıkçı B, Ayoub F, Kim G, Te H, Jeevanandam V, Sabato D, Charlton M. Simultaneous Heart-Liver Transplantation for Congenital Heart Disease in the United States: Rapidly Increasing With Acceptable Outcomes. Hepatology 2021; 73:1464-1477. [PMID: 32559317 DOI: 10.1002/hep.31426] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/14/2020] [Accepted: 06/02/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS There are more adults than children living with congenital heart disease (CHD) in the United States, with a growing proportion requiring heart-liver transplantation (HLT). Our aim was to ascertain the frequency, outcomes, and prognostic factors in this patient population. APPROACH AND RESULTS United Network for Organ Sharing data on adult patients who underwent heart transplantation (HT) from 2009 through March 2020 were analyzed. The primary study outcome was patient survival. Cox proportional-hazards modeling assessed for mortality associations. There were 1,084 HT recipients: 817 (75.4%) CHD HTs only, 74 (6.8%) CHD HLTs, 179 (16.5%) non-CHD HLTs, and 14 (1.3%) heart-liver-kidney transplants. The number of CHD HLTs increased from a prior rate of 4/year to 21/year in 2019. Among patients with CHD, the 5-year survival rates were 74.1% and 73.6% in HTs only and HLTs, respectively (P = 0.865). There was a higher rate of allograft failure attributable to rejection in CHD HTs only compared with CHD HLTs (3.2% versus 0.4%; P = 0.014). Only 25 out of 115 HT-performing hospitals undertook CHD HLTs. Higher-volume centers (averaging one CHD HLT per year) had a 5-year patient survival rate of 83.0% compared with 61.3% in lower-volume centers (P = 0.079). Among HLT recipients, total bilirubin (hazard ratio [HR], 1.06; 95% confidence interval [CI], 1.01-1.12) and diabetes (HR = 2.97, 95% CI = 1.21-7.31) were independently associated with increased mortality risk, whereas CHD and age were not. CONCLUSIONS The rate of HLT for adult CHD in the United States is rising dramatically. The survival outcomes between CHD HT only and CHD HLT groups are comparable; however, the HLT group had lower rates of acute rejection. Among HLT recipients, diabetes and elevated bilirubin are associated with increased posttransplant mortality risk. An average of one CHD HLT per year could be considered a minimum quality metric at transplant centers.
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Affiliation(s)
- Thomas G Cotter
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, IL
| | - Jennifer Wang
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, IL
| | | | | | - Fares Ayoub
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, IL
| | - Gene Kim
- Division of Cardiology, The University of Chicago Medicine, Chicago, IL
| | - Helen Te
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, IL
| | | | - Diego Sabato
- Department of Surgery, The University of Chicago Medicine, Chicago, IL
| | - Michael Charlton
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, IL
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Bickel TJ, Gunasekaran P, Parashara DK, Alpert MA. Mechanical Circulatory Support Prior to Heart Transplantation Predicts Early Post-Operative Stroke. Am J Med Sci 2021; 362:34-38. [PMID: 33785302 DOI: 10.1016/j.amjms.2021.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/04/2021] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Mechanical circulatory support (MCS) devices are often deployed to treat patients with refractory cardiogenic shock, rapid deterioration of heart failure, and inotrope-dependent patients. Stroke is a common complication of MCS therapy. This study assesses the risk of stroke during the early post-heart transplantation (HT) period (days from successful HT to discharge or death) in patients who received MCS therapy leading to HT. METHODS Data were derived from the United Organ Sharing (UNOS) database. MCS modalities studied include left ventricular assist devices (LVAD), right ventricular assist devices (RVAD), biventricular ventricular assist devices (BiVAD), and extra-corporeal membrane oxygenation (ECMO). A multiple logistic regression model was used to determine the risk of stroke during the early post-HT period associated in patients treated with MCS leading to HT. RESULTS Between 1988 and 2014, 10,258 patients received MCS therapy leading to HT. Of these, 160 patients (1.96%) developed stroke during the early post-HT period. Multiple regression analysis showed that MCS modalities and associated odds ratios for early post-HT stroke and associated 95% confidence intervals were as follows: LVAD (1.44, 0.70-2.94), RVAD (2.89, 1.03-8.05, BiVAD (3.24, 1.15-9.10), ECMO (2.27 (1.17-4.40), and any MCS (1.60 (1.20-2.12). CONCLUSIONS With the exception of left ventricular assist devices, use of MCS modalities leading to HT is significantly and independently associated with stroke during the early post-HT period.
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Affiliation(s)
| | | | - Deepak K Parashara
- Kansas City Veterans Administration Medical Center, Kansas City, KS, USA
| | - Martin A Alpert
- Columbia School of Medicine, University of Missouri, Columbia, MO, USA.
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Bakir NH, Finnan MJ, MacGregor RM, Schilling JD, Ewald GA, Kotkar KD, Itoh A, Damiano RJ, Moon MR, Masood MF. Cardiac allograft rejection in the current era of continuous flow left ventricular assist devices. J Thorac Cardiovasc Surg 2020; 163:124-134.e8. [PMID: 33012541 DOI: 10.1016/j.jtcvs.2020.06.142] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 05/28/2020] [Accepted: 06/08/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Left ventricular assist device (LVAD) implantation has been shown to increase allosensitization before orthotopic heart transplantation, but the influence of LVAD support on posttransplant rejection is controversial. This study examines the postoperative incidence of acute cellular rejection (ACR) in patients bridged with continuous flow LVAD (CF-LVAD) relative to primary transplant (Primary Tx). METHODS All patients who underwent orthotopic heart transplantation at our institution between July 2006 and March 2019 were retrospectively reviewed (n = 395). Patients were classified into Primary Tx (n = 145) and CF-LVAD (n = 207) groups. Propensity score matching on 13 covariates implemented a 0.1 caliper logistic model with nearest neighbor 1:1 matching. Development of moderate to severe (ie, 2R/3R) rejection was evaluated using a competing risks model. Potential predictors of 2R/3R ACR were evaluated using Fine-Gray regression on the marginal subdistribution hazard. RESULTS Propensity score matching yielded 122 patients in each group (n = 244). At 12 and 24 months, the cumulative incidence of 2R/3R ACR was 17% and 23% for the CF-LVAD group and 26% and 31%, respectively, for the Primary Tx group (P = .170). CF-LVAD was not predictive of 2R/3R rejection on multivariable Fine-Gray regression (subdistribution hazard ratio, 0.73; 95% confidence interval, 0.40-1.33; P = .301). There was no difference in the 5-year incidence of antibody mediated rejection (10% [n = 12] vs 9% [n = 11]; P = .827). CONCLUSIONS After adjusting for covariates, CF-LVAD was not associated with an increased risk of moderate to severe ACR during the 24 months after cardiac transplantation. Further investigation is warranted with larger cohorts, but CF-LVAD may have minimal influence on posttransplant ACR.
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Affiliation(s)
- Nadia H Bakir
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo
| | - Michael J Finnan
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo
| | - Robert M MacGregor
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo
| | - Joel D Schilling
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo; Department of Pathology and Immunology, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo
| | - Gregory A Ewald
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo
| | - Kunal D Kotkar
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo
| | - Akinobu Itoh
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo
| | - Muhammad F Masood
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo.
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