1
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DeBerge M, Schroth S, Du F, Yeap XY, Wang JJ, Zhang ZJ, Ansari MJ, Scott EA, Thorp EB. Hypoxia inducible factor 2α promotes tolerogenic macrophage development during cardiac transplantation through transcriptional regulation of colony stimulating factor 1 receptor. Proc Natl Acad Sci U S A 2024; 121:e2319623121. [PMID: 38889142 PMCID: PMC11214057 DOI: 10.1073/pnas.2319623121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 05/20/2024] [Indexed: 06/20/2024] Open
Abstract
Solid organ transplantation mobilizes myeloid cells, including monocytes and macrophages, which are central protagonists of allograft rejection. However, myeloid cells can also be functionally reprogrammed by perioperative costimulatory blockade to promote a state of transplantation tolerance. Transplantation tolerance holds promise to reduce complications from chronic immunosuppression and promote long-term survival in transplant recipients. We sought to identify different mediators of transplantation tolerance by performing single-cell RNA sequencing of acute rejecting or tolerized cardiac allografts. This led to the unbiased identification of the transcription factor, hypoxia inducible factor (HIF)-2α, in a subset of tolerogenic monocytes. Using flow cytometric analyses and mice with conditional loss or gain of function, we uncovered that myeloid cell expression of HIF-2α was required for costimulatory blockade-induced transplantation tolerance. While HIF-2α was dispensable for mobilization of tolerogenic monocytes, which were sourced in part from the spleen, it promoted the expression of colony stimulating factor 1 receptor (CSF1R). CSF1R mediates monocyte differentiation into tolerogenic macrophages and was found to be a direct transcriptional target of HIF-2α in splenic monocytes. Administration of the HIF stabilizer, roxadustat, within micelles to target myeloid cells, increased HIF-2α in splenic monocytes, which was associated with increased CSF1R expression and enhanced cardiac allograft survival. These data support further exploration of HIF-2α activation in myeloid cells as a therapeutic strategy for transplantation tolerance.
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Affiliation(s)
- Matthew DeBerge
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL60611
- Department of Anesthesiology, Critical Care and Pain Medicine, University of Texas Health Science Center, Houston, TX77030
| | - Samantha Schroth
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL60611
| | - Fanfan Du
- Department of Biomedical Engineering, Northwestern University, Evanston, IL60208
| | - Xin Yi Yeap
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL60611
| | - Jiao-Jing Wang
- Department of Surgery, Comprehensive Transplant Center, Northwestern University, Chicago, IL60611
| | - Zheng Jenny Zhang
- Department of Surgery, Comprehensive Transplant Center, Northwestern University, Chicago, IL60611
| | - Mohammed Javeed Ansari
- Division of Nephrology and Hypertension, Feinberg School of Medicine, Northwestern University, Chicago, IL60611
| | - Evan A. Scott
- Department of Biomedical Engineering, Northwestern University, Evanston, IL60208
| | - Edward B. Thorp
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL60611
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2
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Bart NK, Macdonald PS. Understanding Tricuspid Regurgitation Post Cardiac Transplantation; Why "Anatomical" and "Functional" Just Won't Cut It. Transplantation 2024; 108:662-668. [PMID: 37578343 DOI: 10.1097/tp.0000000000004740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Tricuspid regurgitation (TR) is common after cardiac transplantation and results in poorer outcomes. Transplant recipients are at high prohibitive risk for redo surgical procedures because of risks associated with a subsequent sternotomy, immunosuppression, and renal failure. Percutaneous therapies have recently become available and may be an option for transplant recipients. However, transplant recipients have complex geometry, and there is a myriad of causes of TR posttransplant. There is a need for careful patient selection for all percutaneous valve interventions, and this is particularly true in transplant recipients who suffer from right ventricular failure and rejection and may undergo repeated endomyocardial biopsies. Cognizant of the rapid developments in this space, this review article focuses on the causes of TR, treatments, and future therapies in heart transplantation recipients to the transplant cardiologist navigate this complex area.
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Affiliation(s)
- Nicole K Bart
- Heart Transplant Program, St Vincent's Hospital, Darlinghurst, NSW, Australia
- School of Medicine, University of Notre Dame, Sydney, NSW, Australia
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
| | - Peter S Macdonald
- Heart Transplant Program, St Vincent's Hospital, Darlinghurst, NSW, Australia
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
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3
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Arjomandi Rad A, Fleet B, Zubarevich A, Nanchahal S, Naruka V, Subbiah Ponniah H, Vardanyan R, Sardari Nia P, Loubani M, Moorjani N, Schmack B, Punjabi PP, Schmitto J, Ruhparwar A, Weymann A. Left ventricular assist device implantation and concomitant mitral valve surgery: A systematic review and meta-analysis. Artif Organs 2024; 48:16-27. [PMID: 37822301 DOI: 10.1111/aor.14659] [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: 06/16/2023] [Revised: 08/29/2023] [Accepted: 09/21/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The management of concomitant valvular lesions in patients undergoing left ventricular assist device (LVAD) implantation remains a topic of debate. This systematic review and meta-analysis aimed to evaluate the existing evidence on postoperative outcomes following LVAD implantation, with and without concomitant MV surgery. METHODS A systematic database search was conducted as per PRISMA guidelines, of original articles comparing LVAD alone to LVAD plus concomitant MV surgery up to February 2023. The primary outcomes assessed were overall mortality and early mortality, while secondary outcomes included stroke, need for right ventricular assist device (RVAD) implantation, postoperative mitral valve regurgitation, major bleeding, and renal dysfunction. RESULTS The meta-analysis included 10 studies comprising 32 184 patients. It revealed that concomitant MV surgery during LVAD implantation did not significantly affect overall mortality (OR:0.83; 95% CI: 0.53 to 1.29; p = 0.40), early mortality (OR:1.17; 95% CI: 0.63 to 2.17; p = 0.63), stroke, need for RVAD implantation, postoperative mitral valve regurgitation, major bleeding, or renal dysfunction. These findings suggest that concomitant MV surgery appears not to confer additional benefits in terms of these clinical outcomes. CONCLUSION Based on the available evidence, concomitant MV surgery during LVAD implantation does not appear to have a significant impact on postoperative outcomes. However, decision-making regarding MV surgery should be individualized, considering patient-specific factors and characteristics. Further research with prospective studies focusing on specific patient populations and newer LVAD devices is warranted to provide more robust evidence and guide clinical practice in the management of valvular lesions in LVAD recipients.
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Affiliation(s)
- Arian Arjomandi Rad
- Medical Sciences Division, University of Oxford, Oxford, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Ben Fleet
- School of Medicine, Lancaster University, Lancaster, UK
| | - Alina Zubarevich
- Department of Cardiothoracic Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Sukanya Nanchahal
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Vinci Naruka
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Robert Vardanyan
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Peyman Sardari Nia
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth NHS Trust, Cambridge, UK
| | - Bastian Schmack
- Department of Cardiothoracic Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Prakash P Punjabi
- Department of Cardiothoracic Surgery, National Heart and Lung Institute, Imperial College London, London, UK
| | - Jan Schmitto
- Department of Cardiothoracic Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Arjang Ruhparwar
- Department of Cardiothoracic Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Alexander Weymann
- Department of Cardiothoracic Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
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4
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Kveton M, Hudec L, Vykopal I, Halinkovic M, Laco M, Felsoova A, Benesova W, Fabian O. Digital pathology in cardiac transplant diagnostics: from biopsies to algorithms. Cardiovasc Pathol 2024; 68:107587. [PMID: 37926351 DOI: 10.1016/j.carpath.2023.107587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/03/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023] Open
Abstract
In the field of heart transplantation, the ability to accurately and promptly diagnose cardiac allograft rejection is crucial. This comprehensive review explores the transformative role of digital pathology and computational pathology, especially through machine learning, in this critical domain. These methodologies harness large datasets to extract subtle patterns and valuable information that extend beyond human perceptual capabilities, potentially enhancing diagnostic outcomes. Current research indicates that these computer-based systems could offer accuracy and performance matching, or even exceeding, that of expert pathologists, thereby introducing more objectivity and reducing observer variability. Despite promising results, several challenges such as limited sample sizes, diverse data sources, and the absence of standardized protocols pose significant barriers to the widespread adoption of these techniques. The future of digital pathology in heart transplantation diagnostics depends on utilizing larger, more diverse patient cohorts, standardizing data collection, processing, and evaluation protocols, and fostering collaborative research efforts. The integration of various data types, including clinical, demographic, and imaging information, could further refine diagnostic precision. As researchers address these challenges and promote collaborative efforts, digital pathology has the potential to become an integral part of clinical practice, ultimately improving patient care in heart transplantation.
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Affiliation(s)
- Martin Kveton
- Third Faculty of Medicine, Charles University, Prague, Czech Republic; Clinical and Transplant Pathology Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
| | - Lukas Hudec
- Faculty of Informatics and Information Technologies, Slovak University of Technology, Bratislava, Slovakia
| | - Ivan Vykopal
- Faculty of Informatics and Information Technologies, Slovak University of Technology, Bratislava, Slovakia
| | - Matej Halinkovic
- Faculty of Informatics and Information Technologies, Slovak University of Technology, Bratislava, Slovakia
| | - Miroslav Laco
- Faculty of Informatics and Information Technologies, Slovak University of Technology, Bratislava, Slovakia
| | - Andrea Felsoova
- Clinical and Transplant Pathology Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Department of Histology and Embryology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Wanda Benesova
- Faculty of Informatics and Information Technologies, Slovak University of Technology, Bratislava, Slovakia
| | - Ondrej Fabian
- Clinical and Transplant Pathology Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Department of Pathology and Molecular Medicine, Third Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
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Kafili G, Kabir H, Jalali Kandeloos A, Golafshan E, Ghasemi S, Mashayekhan S, Taebnia N. Recent advances in soluble decellularized extracellular matrix for heart tissue engineering and organ modeling. J Biomater Appl 2023; 38:577-604. [PMID: 38006224 PMCID: PMC10676626 DOI: 10.1177/08853282231207216] [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] [Indexed: 11/26/2023]
Abstract
Despite the advent of tissue engineering (TE) for the remodeling, restoring, and replacing damaged cardiovascular tissues, the progress is hindered by the optimal mechanical and chemical properties required to induce cardiac tissue-specific cellular behaviors including migration, adhesion, proliferation, and differentiation. Cardiac extracellular matrix (ECM) consists of numerous structural and functional molecules and tissue-specific cells, therefore it plays an important role in stimulating cell proliferation and differentiation, guiding cell migration, and activating regulatory signaling pathways. With the improvement and modification of cell removal methods, decellularized ECM (dECM) preserves biochemical complexity, and bio-inductive properties of the native matrix and improves the process of generating functional tissue. In this review, we first provide an overview of the latest advancements in the utilization of dECM in in vitro model systems for disease and tissue modeling, as well as drug screening. Then, we explore the role of dECM-based biomaterials in cardiovascular regenerative medicine (RM), including both invasive and non-invasive methods. In the next step, we elucidate the engineering and material considerations in the preparation of dECM-based biomaterials, namely various decellularization techniques, dECM sources, modulation, characterizations, and fabrication approaches. Finally, we discuss the limitations and future directions in fabrication of dECM-based biomaterials for cardiovascular modeling, RM, and clinical translation.
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Affiliation(s)
- Golara Kafili
- Institute for Nanoscience and Nanotechnology, Sharif University of Technology, Tehran, Iran
| | - Hannaneh Kabir
- Molecular Cell Biomechanics Laboratory, Departments of Bioengineering and Mechanical Engineering, University of California, Berkeley, CA, USA
| | | | - Elham Golafshan
- Institute for Nanoscience and Nanotechnology, Sharif University of Technology, Tehran, Iran
| | - Sara Ghasemi
- Department of Chemical and Petroleum Engineering, Sharif University of Technology, Tehran, Iran
| | - Shohreh Mashayekhan
- Institute for Nanoscience and Nanotechnology, Sharif University of Technology, Tehran, Iran
- Department of Chemical and Petroleum Engineering, Sharif University of Technology, Tehran, Iran
| | - Nayere Taebnia
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
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6
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Masarone D, Kittleson MM, Falco L, Martucci ML, Catapano D, Brescia B, Petraio A, De Feo M, Pacileo G. The ABC of Heart Transplantation-Part 1: Indication, Eligibility, Donor Selection, and Surgical Technique. J Clin Med 2023; 12:5217. [PMID: 37629260 PMCID: PMC10455167 DOI: 10.3390/jcm12165217] [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: 07/21/2023] [Revised: 08/04/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Cardiac transplantation represents the gold standard of treatment for selected patients with advanced heart failure who have poor functional capacity and prognosis despite guideline-directed medical therapy and device-based therapy. Proper patient selection and appropriate referral of patients to centers for the treatment of advanced heart failure are the first but decisive steps for screening patients eligible for cardiac transplantation. The eligibility and the decision to list for cardiac transplantation, even for patients with relative contraindications, are based on a multidisciplinary evaluation of a transplant team. This review will discuss the practical indications, the process of patient eligibility for cardiac transplantation, the principle of donor selection, as well as the surgical technique.
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Affiliation(s)
- Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Michelle M. Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Hospital, Los Angeles, CA 90048, USA
| | - Luigi Falco
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Maria L. Martucci
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Dario Catapano
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Benedetta Brescia
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
| | - Andrea Petraio
- Heart Transplant Unit, Department of Cardiac Surgery and Transplants, AORN dei Colli Monaldi Hospital, 80131 Naples, Italy
| | - Marisa De Feo
- Cardiac Surgery Unit, Department of Cardiac Surgery and Transplants, AORN dei Colli Monaldi Hospital, 80131 Naples, Italy
| | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
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7
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Masarone D, Houston B, Falco L, Martucci ML, Catapano D, Valente F, Gravino R, Contaldi C, Petraio A, De Feo M, Tedford RJ, Pacileo G. How to Select Patients for Left Ventricular Assist Devices? A Guide for Clinical Practice. J Clin Med 2023; 12:5216. [PMID: 37629257 PMCID: PMC10455625 DOI: 10.3390/jcm12165216] [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: 07/22/2023] [Revised: 08/04/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
In recent years, a significant improvement in left ventricular assist device (LVAD) technology has occurred, and the continuous-flow devices currently used can last more than 10 years in a patient. Current studies report that the 5-year survival rate after LVAD implantation approaches that after a heart transplant. However, the outcome is influenced by the correct selection of the patients, as well as the choice of the optimal time for implantation. This review summarizes the indications, the red flags for prompt initiation of LVAD evaluation, and the principles for appropriate patient screening.
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Affiliation(s)
- Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
| | - Brian Houston
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC 158155, USA (R.J.T.)
| | - Luigi Falco
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
| | - Maria L. Martucci
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
| | - Dario Catapano
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
| | - Fabio Valente
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
| | - Rita Gravino
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
| | - Carla Contaldi
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
| | - Andrea Petraio
- Heart Transplant Unit, Department of Cardiac Surgery and Transplant, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
| | - Marisa De Feo
- Cardiac Surgery Unit, Department of Cardiac Surgery and Transplant, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
| | - Ryan J. Tedford
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC 158155, USA (R.J.T.)
| | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
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Cho H, Song I, Jo U, Jeong J, Koo HJ, Yang DH, Jung S, Song JS, Cho K. Primary cardiac sarcomas: A clinicopathologic study in a single institution with 25 years of experience with an emphasis on MDM2 expression and adjuvant therapy for prognosis. Cancer Med 2023; 12:16815-16828. [PMID: 37395142 PMCID: PMC10501235 DOI: 10.1002/cam4.6303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 06/04/2023] [Accepted: 06/22/2023] [Indexed: 07/04/2023] Open
Abstract
BACKGROUND Primary cardiac sarcomas are rare and their clinicopathologic features are heterogeneous. Among them, particularly intimal sarcoma is a diagnostic challenge due to nonspecific histologic features. Recently, MDM2 amplification reported to be a characteristic genetic event in the intimal sarcoma. In this study, we aimed to identify the types and incidence of primary cardiac sarcomas that occurred over 25 years in tertiary medical institutions, and to find clinicopatholgical significance through reclassification of diagnoses using additional immunohistochemistry (IHC). METHODS We reviewed the primary cardiac sarcoma cases between January 1993 and June 2018 at Asan Medical Center, South Korea, with their clinicopathologic findings, and reclassified the subtypes, especially using IHC for MDM2 and then, analyzed the significance of prognosis. RESULTS Forty-eight (6.8%) cases of a primary cardiac sarcoma were retrieved. The tumors most frequently involved the right atrium (n = 25, 52.1%), and the most frequent tumor subtype was angiosarcoma (n = 23, 47.9%). Seven cases (53.8%) were newly reclassified as an intimal sarcoma by IHC for MDM2. Twenty-nine (60.4%) patients died of disease (mean, 19.8 months). Four patients underwent a heart transplantation and had a median survival of 26.8 months. This transplantation group tended to show good clinical outcomes in the earlier stages, but this was not statistically significant (p = 0.318). MDM2 positive intimal sarcoma showed the better overall survival (p = 0.003) than undifferentiated pleomorphic sarcoma. Adjuvant treatment is beneficial for patient survival (p < 0.001), particularly in angiosarcoma (p < 0.001), but not in intimal sarcoma (p = 0.154). CONCLUSION Our study supports the use of adjuvant treatment in primary cardiac sarcoma, as it was associated with a significantly better overall survival rate. Further consideration of tumor histology may be important in determining the optimal use of adjuvant treatment for different types of sarcomas. Therefore, accurate diagnosis by MDM2 test is important condsidering patient's prognosis and treatment.
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Affiliation(s)
- Haeyon Cho
- Department of PathologyUniversity of Ulsan College of Medicine, Asan Medical CenterSeoulRepublic of Korea
| | - In‐Hye Song
- Department of PathologyUniversity of Ulsan College of Medicine, Asan Medical CenterSeoulRepublic of Korea
| | - Uiree Jo
- Department of PathologyUniversity of Ulsan College of Medicine, Asan Medical CenterSeoulRepublic of Korea
| | - Ji‐Seon Jeong
- Department of PathologyUniversity of Ulsan College of Medicine, Asan Medical CenterSeoulRepublic of Korea
| | - Hyun Jung Koo
- Department of Radiology and Research Institute of RadiologyUniversity of Ulsan College of Medicine, Asan Medical CenterSeoulRepublic of Korea
| | - Dong Hyun Yang
- Department of Radiology and Research Institute of RadiologyUniversity of Ulsan College of Medicine, Asan Medical CenterSeoulRepublic of Korea
| | - Sung‐Ho Jung
- Department of Thoracic and Cardiovascular SurgeryUniversity of Ulsan College of Medicine, Asan Medical CenterSeoulRepublic of Korea
| | - Joon Seon Song
- Department of PathologyUniversity of Ulsan College of Medicine, Asan Medical CenterSeoulRepublic of Korea
| | - Kyung‐Ja Cho
- Department of PathologyUniversity of Ulsan College of Medicine, Asan Medical CenterSeoulRepublic of Korea
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9
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Cho S, Aakash P, Lee S, Yoon YS. Endothelial cell direct reprogramming: Past, present, and future. J Mol Cell Cardiol 2023; 180:22-32. [PMID: 37080451 PMCID: PMC10330356 DOI: 10.1016/j.yjmcc.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/04/2023] [Accepted: 04/17/2023] [Indexed: 04/22/2023]
Abstract
Ischemic cardiovascular disease still remains as a leading cause of morbidity and mortality despite various medical, surgical, and interventional therapy. As such, cell therapy has emerged as an attractive option because it tackles underlying problem of the diseases by inducing neovascularization in ischemic tissue. After overall failure of adult stem or progenitor cells, studies attempted to generate endothelial cells (ECs) from pluripotent stem cells (PSCs). While endothelial cells (ECs) differentiated from PSCs successfully induced vascular regeneration, differentiating volatility and tumorigenic potential is a concern for their clinical applications. Alternatively, direct reprogramming strategies employ lineage-specific factors to change cell fate without achieving pluripotency. ECs have been successfully reprogrammed via ectopic expression of transcription factors (TFs) from endothelial lineage. The reprogrammed ECs induced neovascularization in vitro and in vivo and thus demonstrated their therapeutic value in animal models of vascular insufficiency. Methods of delivering reprogramming factors include lentiviral or retroviral vectors and more clinically relevant, non-integrative adenoviral and episomal vectors. Most studies made use of fibroblast as a source cell for reprogramming, but reprogrammability of other clinically relevant source cell types has to be evaluated. Specific mechanisms and small molecules that are involved in the aforementioned processes tackles challenges associated with direct reprogramming efficiency and maintenance of reprogrammed EC characteristics. After all, this review provides summary of past and contemporary methods of direct endothelial reprogramming and discusses the future direction to overcome these challenges to acquire clinically applicable reprogrammed ECs.
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Affiliation(s)
- Seonggeon Cho
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Parthasarathy Aakash
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Sangho Lee
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Young-Sup Yoon
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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10
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Yuan L, Ma W, Cui J, Liu J, Yang Z, Yang S, Zhang H, Wang F, Liu H, Wang C, Sun X. Mildly Elevated Pulmonary Artery Systolic Pressure is Associated with Extracorporeal Membrane Oxygenation Support after Heart Transplantation. J Card Surg 2023. [DOI: 10.1155/2023/8877476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Background. Pulmonary hypertension is a well-known risk factor for hemodynamic instability after heart transplantation. However, it remains unclear whether a mild elevation of pulmonary artery systolic pressure (PASP) is associated with higher risks of graft dysfunction and resultant extracorporeal membrane oxygenation (ECMO) support. Methods. From 2016 to 2021, 102 adult recipients undergoing orthotopic heart transplantation at our institution were investigated (mean age, 48.5 ± 13.2 years; 22.5% female). This study cohort was stratified into 3 groups based on the PASP measured by right heart catheterization before surgery: >50 mmHg, 35–50 mmHg, and <35 mmHg. The primary end point was ECMO support after procedure. Results. ECMO was implemented in 24 (23.5%) patients due to difficult weaning from cardiopulmonary bypass or cardiac low output in the intensive care unit, which was likely to be associated with higher mortality (
). Age, gender, comorbidities, preoperative medications, and graft ischemia time were comparable across the 3 groups. The use of ECMO was significantly more common in patients with baseline PASP >50 mmHg (11/36, 30.6%) and 35–50 mmHg (12/38, 31.6%), while only 1 (3.6%) patient with baseline PASP <35 mmHg required ECMO support after transplant (
). Multivariate logistic models demonstrated that PASP (odds ratio = 2.34;
) and cardiopulmonary bypass time (odds ratio = 1.01;
) were independent risk factors for postoperative ECMO. Conclusions. A mild elevation of pretransplant PASP (e.g., 35–50 mmHg) is related to low cardiac output and subsequent ECMO after heart transplantation, for which prompt administration of vasodilators before transplant may be protective.
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11
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Rabbath X, Pelletier-Galarneau M, Tremblay-Gravel M, Noly PE, Racine N, Tan S. Value of CT and 18F-FDG PET/CT Imaging for Preoperative Screening in Advanced Heart Failure Therapies Candidates. CJC Open 2023. [DOI: 10.1016/j.cjco.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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12
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Harris NR, Bálint L, Dy DM, Nielsen NR, Méndez HG, Aghajanian A, Caron KM. The ebb and flow of cardiac lymphatics: a tidal wave of new discoveries. Physiol Rev 2023; 103:391-432. [PMID: 35953269 PMCID: PMC9576179 DOI: 10.1152/physrev.00052.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 06/16/2022] [Accepted: 07/18/2022] [Indexed: 12/16/2022] Open
Abstract
The heart is imbued with a vast lymphatic network that is responsible for fluid homeostasis and immune cell trafficking. Disturbances in the forces that regulate microvascular fluid movement can result in myocardial edema, which has profibrotic and proinflammatory consequences and contributes to cardiovascular dysfunction. This review explores the complex relationship between cardiac lymphatics, myocardial edema, and cardiac disease. It covers the revised paradigm of microvascular forces and fluid movement around the capillary as well as the arsenal of preclinical tools and animal models used to model myocardial edema and cardiac disease. Clinical studies of myocardial edema and their prognostic significance are examined in parallel to the recent elegant animal studies discerning the pathophysiological role and therapeutic potential of cardiac lymphatics in different cardiovascular disease models. This review highlights the outstanding questions of interest to both basic scientists and clinicians regarding the roles of cardiac lymphatics in health and disease.
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Affiliation(s)
- Natalie R Harris
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - László Bálint
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Danielle M Dy
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Natalie R Nielsen
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Hernán G Méndez
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Amir Aghajanian
- Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kathleen M Caron
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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13
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Garry MG, Caplan AL, Garry DJ. Emerging technologies and ethics-exogenic chimeric humanized organs. Am J Transplant 2022; 22:2786-2790. [PMID: 36052557 PMCID: PMC10087366 DOI: 10.1111/ajt.17188] [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: 03/10/2021] [Revised: 08/08/2022] [Accepted: 08/25/2022] [Indexed: 01/25/2023]
Abstract
Organ transplantation is limited due to the scarcity of donor organs. In order to expand the supply of organs for transplantation, interspecies chimeras have been examined as a potential future source of humanized organs. Recent studies using gene editing technologies in combination with somatic cell nuclear transfer technology and hiPSCs successfully engineered humanized skeletal muscle in the porcine embryo. As these technologies progress, there are ethical issues that warrant consideration and dialogue.
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Affiliation(s)
- Mary G Garry
- Paul and Sheila Wellstone Muscular Dystrophy Center, University of Minnesota, Minneapolis, Minnesota, USA.,Stem Cell Institute, University of Minnesota, Minneapolis, Minnesota, USA.,Regenerative Medicine and Sciences Program, University of Minnesota, Minneapolis, Minnesota, USA.,NorthStar Genomics, LLC, Eagan, Minnesota, USA
| | - Arthur L Caplan
- Division of Medical Ethics, New York University Langone Medical Center, New York, New York, USA
| | - Daniel J Garry
- Paul and Sheila Wellstone Muscular Dystrophy Center, University of Minnesota, Minneapolis, Minnesota, USA.,Stem Cell Institute, University of Minnesota, Minneapolis, Minnesota, USA.,Regenerative Medicine and Sciences Program, University of Minnesota, Minneapolis, Minnesota, USA.,NorthStar Genomics, LLC, Eagan, Minnesota, USA
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14
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Daubenspeck DK. Mechanical circulatory support devices: historical overview and modern approach. Int Anesthesiol Clin 2022; 60:1-7. [PMID: 35972151 DOI: 10.1097/aia.0000000000000376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Danisa K Daubenspeck
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
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15
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Jung C, Oh JE, Lee S, Yoon YS. Generation and Application of Directly Reprogrammed Endothelial Cells. Korean Circ J 2022; 52:643-658. [PMID: 36097834 PMCID: PMC9470489 DOI: 10.4070/kcj.2022.0190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/11/2022] [Indexed: 11/15/2022] Open
Abstract
Cell-based therapy has emerged as a promising option for treating advanced ischemic cardiovascular disease by inducing vascular regeneration. However, clinical trials with adult cells turned out disappointing in general. As a newer approach, direct reprogramming has emerged to efficiently generate endothelial cells (ECs), which can promote neovascularization and vascular regeneration. This review provides recent updates on the direct endothelial reprogramming. In general, directly reprogrammed ECs can be generated by two approaches: one by transitioning through a plastic intermediate state and the other in a one-step transition without any intermediate states toward pluripotency. Moreover, the methods to deliver reprogramming factors and chemicals for the fate conversion are highlighted. Next, the therapeutic effects of the directly reprogrammed ECs on animal models are reviewed in detail. Other applications using directly reprogrammed ECs, such as tissue engineering and disease modeling, are also discussed. Lastly, the remaining questions and foremost challenges are addressed.
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Affiliation(s)
- Cholomi Jung
- Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Eun Oh
- Research and Development Center, KarisBio Inc., Seoul, Korea
| | - Sangho Lee
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Young-Sup Yoon
- Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Korea
- Research and Development Center, KarisBio Inc., Seoul, Korea
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
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16
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Mascaro J. Trasplante cardíaco: estado actual. REVISTA MÉDICA CLÍNICA LAS CONDES 2022. [DOI: 10.1016/j.rmclc.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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17
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Kidney Re-Transplantation after Simultaneous Heart and Kidney Transplant: Case Study and Literature Review. TRANSPLANTOLOGY 2022. [DOI: 10.3390/transplantology3020013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The kidney is one of most frequent transplants to be performed in multi-organ transplantation. A simultaneous heart and kidney transplant (SHKT) is the best-known treatment method in patients with severe heart failure and end-stage renal disease (ESRD). Here, the authors describe the case of a kidney re-transplantation after SHKT, which is in accordance with the majority of studies, and proves the safety of simultaneous procedures. The article highlights the complex care required after the transplant, followed by the multi-factor qualification for re-transplantation. In conclusion, the case shows that SHKT provides long-term favorable outcomes and enables a repeated kidney transplantation with satisfactory one-year follow-up results.
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18
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Yang TW, Song S, Lee HW, Lee BJ. Cardiac rehabilitation in a heart failure patient after left ventricular assist device insertion and subsequent heart transplantation: A case report. World J Clin Cases 2022; 10:2577-2583. [PMID: 35434054 PMCID: PMC8968617 DOI: 10.12998/wjcc.v10.i8.2577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/16/2021] [Accepted: 01/29/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Insertion of a left ventricular assist device (LVAD) and heart transplantation (HT) improve the survival of patients with heart failure. In addition, cardiac rehabilitation (CR) further increases the functional capacity. This case report describes a successful case of CR after LVAD insertion and subsequent HT.
CASE SUMMARY In the present case, during the LVAD insertion period, peak oxygen consumption (VO2) increased by 12.16% after CR. HT was performed 7 mo after the LVAD insertion, and the patient participated in phases I and II CR. The peak VO2 increased from 17.24 to 22.29 mL/kg/min. This improvement was more significant than that reported in previous studies on CR after LVAD insertion or HT. The patient’s quality of life also improved. The total average score of the short form-36 questionnaire increased from 29.5 points at admission to 53.3 points 9 mo after HT.
CONCLUSION A tailored CR program after LVAD insertion or HT may improve the patients’ quality of life and increase survival.
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Affiliation(s)
- Tae Woong Yang
- Department of Rehabilitation Medicine, Biomedical Research Institute, Pusan National University Hospital, Pusan 602-739, South Korea
| | - Seunghwan Song
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Pusan National University Hospital, Pusan 602-739, South Korea
| | - Hye Won Lee
- Division of Cardiology, Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Pusan 602-739, South Korea
| | - Byeong-Ju Lee
- Department of Rehabilitation Medicine, Biomedical Research Institute, Pusan National University Hospital, Pusan 602-739, South Korea
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19
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Agarwal R, Aurora RG, Siswanto BB, Muliawan HS. The prognostic value of neutrophil-to-lymphocyte ratio across all stages of coronary artery disease. Coron Artery Dis 2022; 33:137-143. [PMID: 33826535 DOI: 10.1097/mca.0000000000001040] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The natural history of coronary heart disease (CAD) commonly begins with atherosclerosis, progressing to chronic coronary syndrome (CCS), acute coronary syndrome (ACS), and eventually, heart failure. Despite advancements in preventive and therapeutic strategies, there is room for further cardiovascular risk reduction. Recently, inflammation has emerged as a potential therapeutic target. The neutrophil-to-lymphocyte ratio (NLR) is a novel inflammatory biomarker which predicts poor prognosis in several conditions such as metabolic syndrome, sepsis, malignancy and CAD. In atherosclerosis, a high NLR predicts plaque vulnerability and severe stenosis. This is consistent with observations in CCS, where an elevated NLR predicts long-term major adverse cardiac events (MACEs). In ACS patients, high NLR levels are associated with larger infarct sizes and poor long-term outcomes. Possible reasons for this include failure of fibrinolysis, ischemia-reperfusion injury and in-stent restenosis, all of which are associated with raised NLR levels. Following myocardial infarction, an elevated NLR correlates with pathological cardiac remodeling which propagates chronic heart failure. Finally, in heart failure patients, an elevated NLR predicts long-term MACEs, mortality, and poor left ventricular assist device and transplant outcomes. Further studies must evaluate whether the addition of NLR to current risk-stratification models can better identify high-risk CAD patients.
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Affiliation(s)
- Raksheeth Agarwal
- Faculty of Medicine, Universitas Indonesia, Jl. Salemba Raya No.6, Kenari, Kec. Senen, Jakarta Pusat, DKI Jakarta
| | - Ruth G Aurora
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jl. Let. Jend. S. Parman Kav 87, Jakarta Barat, DKI Jakarta
| | - Bambang B Siswanto
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jl. Let. Jend. S. Parman Kav 87, Jakarta Barat, DKI Jakarta
| | - Hary S Muliawan
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia/Rumah Sakit Universitas Indonesia, Jl. Prof Bahder Djohan, Pondok Cina, Beji, Depok, Jawa Barat, Indonesia
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20
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Frountzas M, Karampetsou N, Nikolaou C, Schizas D, Tsapralis D, Avgerinos D, Toutouzas K. Combined heart and liver transplantation: an updated systematic review. Ann R Coll Surg Engl 2022; 104:88-94. [PMID: 34482766 PMCID: PMC10335029 DOI: 10.1308/rcsann.2021.0103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Combined heart and liver transplantation (CHLT) is one of the most complex procedures of surgery that has been implemented in the last 35 years. The aim of our meta-analysis was to investigate the safety and efficacy of CHLT. MATERIALS The meta-analysis was designed according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) and AMSTAR (A MeaSurement Tool to Assess systematic Reviews) recommendations. A literature search was conducted up to April 2020 using the MEDLINE,® SCOPUS,® ClinicalTrials.gov, Embase™, Cochrane Central Register of Controlled Trials and Google Scholar™ databases. RESULTS Our meta-analysis included 16 studies with 860 patients. The mortality rate following CHLT was 14.1%. One and five-year survival rates were 85.3% and 71.4% while the heart and liver rejection rates were 6.1% and 9.1% respectively. The hospital stay was 25.8 days and the intensive care unit stay was 9.9 days. Pooled values were also calculated for cardiopulmonary bypass duration, units of transfused red blood cells and fresh frozen plasma, postoperative infection rate, mechanical ventilation rate and follow-up duration. CONCLUSIONS Despite its complexity, CHLT is a safe and effective procedure for the management of lethal diseases that lead to progressive heart and/or liver failure. Nevertheless, there must be strict adherence to the indications for surgery, and future studies should compare CHLT with isolated cardiac and hepatic transplantations.
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Affiliation(s)
- M Frountzas
- National and Kapodistrian University of Athens, Greece
| | - N Karampetsou
- National and Kapodistrian University of Athens, Greece
| | - C Nikolaou
- National and Kapodistrian University of Athens, Greece
| | - D Schizas
- National and Kapodistrian University of Athens, Greece
| | | | | | - K Toutouzas
- National and Kapodistrian University of Athens, Greece
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21
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Yi Y, Xie C, Liu J, Zheng Y, Wang J, Lu X. Self-adhesive hydrogels for tissue engineering. J Mater Chem B 2021; 9:8739-8767. [PMID: 34647120 DOI: 10.1039/d1tb01503f] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Hydrogels consisting of a three-dimensional hydrophilic network of biocompatible polymers have been widely used in tissue engineering. Owing to their tunable mechanical properties, hydrogels have been applied in both hard and soft tissues. However, most hydrogels lack self-adhesive properties that enable integration with surrounding tissues, which may result in suture or low repair efficacy. Self-adhesive hydrogels (SAHs), an emerging class of hydrogels based on a combination of three-dimensional hydrophilic networks and self-adhesive properties, continue to garner increased attention in recent years. SAHs exhibit reliable and suitable adherence to tissues, and easily integrate into tissues to promote repair efficiency. SAHs are designed either by mimicking the adhesion mechanism of natural organisms, such as mussels and sandcastle worms, or by using supramolecular strategies. This review summarizes the design and processing strategies of SAHs, clarifies underlying adhesive mechanisms, and discusses their applications in tissue engineering, as well as future challenges.
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Affiliation(s)
- Yating Yi
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China.
| | - Chaoming Xie
- Key Lab of Advanced Technologies of Materials, Ministry of Education, School of Materials Science and Engineering, Southwest Jiaotong University, Chengdu, Sichuan, 610031, China.
| | - Jin Liu
- Lab for Aging Research and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Yonghao Zheng
- School of Optoelectronic Science and Technology, University of Electronic Science and Technology of China, Chengdu 610054, China.
| | - Jun Wang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China.
| | - Xiong Lu
- Key Lab of Advanced Technologies of Materials, Ministry of Education, School of Materials Science and Engineering, Southwest Jiaotong University, Chengdu, Sichuan, 610031, China.
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22
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Mazzucco GA, Pilon L, Escalante JP, Chichizola N, Torres-Castro R. Cardiac Rehabilitation in a Patient With Severe Heart Failure and Ventricular Septal Defect Secondary to Acute Myocardial Infarction. Cureus 2021; 13:e19901. [PMID: 34966609 PMCID: PMC8710137 DOI: 10.7759/cureus.19901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2021] [Indexed: 11/16/2022] Open
Abstract
The treatment of choice for patients with advanced heart failure (HF) and with limiting symptoms with evidence of a poor prognosis despite optimal conventional treatment is a heart transplant. However, there is little literature dealing with the effects of cardiovascular prehabilitation with an important change in physical capacity, which can influence the admission on the waiting list for a heart transplant. We presented one young male, smoker, with no prior history of cardiovascular disease, severe ventricular dysfunction, interventricular defect, and HF. It was decided to implant a cardioverter-defibrillator as primary prevention of sudden death and start the pre-cardiac transplant evaluation and subsequent inclusion in the waiting list on an elective basis. While waiting for the transplant, cardiopulmonary rehabilitation (CPR) was indicated. After 15 months of CPR, the patient improved his left ventricular ejection fraction (LVEF; 20% to 40%), systolic pulmonary artery pressure (55 to 40 mmHg), and peak oxygen uptake (23.9 to 29.1 ml/kg/min). In this patient, a program of CPR improved cardiac function and physical capacity, allowing him to be removed from the national waiting list for a heart transplant.
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Affiliation(s)
- Guillermo A Mazzucco
- Cardiopulmonary Rehabilitation Unit, Instituto Cardiovascular de Rosario, Rosario, ARG
- Unidad de Investigación en Kinesiología Cardiorespiratoria, Universidad del Gran Rosario, Rosario, ARG
| | - Leonardo Pilon
- Cardiology, Instituto Cardiovascular de Rosario, Rosario, ARG
| | | | | | - Rodrigo Torres-Castro
- PhysioEvidence, International Physiotherapy Research Network, Barcelona, ESP
- Departamento de Kinesiología, Facultad de Medicina, Universidad de Chile, Santiago, CHL
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23
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Fink T, Sciacca V, Bergau L, Khalaph M, Braun M, Imnadze G, El Hamriti M, Sommer P, Sohns C. Preserved electrical conduction between donor and recipient right atria as the cause of macroreentrant atrial tachycardia after heart transplantation. Herzschrittmacherther Elektrophysiol 2021; 33:77-80. [PMID: 34669032 DOI: 10.1007/s00399-021-00814-y] [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: 09/24/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022]
Abstract
Atrial arrhythmias after heart transplantation are common and usually originate from reentrant circuits inside the donor and recipient atria. A case is presented of macroreentrant atrial tachycardia with a reentry circuit incorporating preserved electrical conduction from the donor and recipient right atria. An invasive electrophysiological study including high-density electroanatomical mapping with a multipolar catheter was performed during tachycardia. A reentry circuit with an area of slow conduction at the supero-lateral aspect of the surgical anastomosis could be demonstrated. Catheter ablation at the site of slow conduction successfully terminated and permanently suppressed the tachycardia.
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Affiliation(s)
- Thomas Fink
- Klinik für Elektrophysiologie und Rhythmologie, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany.
| | - Vanessa Sciacca
- Klinik für Elektrophysiologie und Rhythmologie, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany
| | - Leonard Bergau
- Klinik für Elektrophysiologie und Rhythmologie, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany
| | - Moneeb Khalaph
- Klinik für Elektrophysiologie und Rhythmologie, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany
| | - Martin Braun
- Klinik für Elektrophysiologie und Rhythmologie, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany
| | - Guram Imnadze
- Klinik für Elektrophysiologie und Rhythmologie, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany
| | - Mustapha El Hamriti
- Klinik für Elektrophysiologie und Rhythmologie, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany
| | - Philipp Sommer
- Klinik für Elektrophysiologie und Rhythmologie, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany
| | - Christian Sohns
- Klinik für Elektrophysiologie und Rhythmologie, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany
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24
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Brahmbhatt DH, Rao V. Commentary: If the first time is the best time, should there ever be a next time? J Thorac Cardiovasc Surg 2021:S0022-5223(21)01418-5. [PMID: 34688489 DOI: 10.1016/j.jtcvs.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 10/02/2021] [Accepted: 10/04/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Darshan H Brahmbhatt
- Ted Rogers Centre for Heart Function Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, University of Toronto, Toronto, Ontario, Canada; National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Vivek Rao
- Ted Rogers Centre for Heart Function Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, University of Toronto, Toronto, Ontario, Canada.
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25
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Oka T, Hamano T, Ohtani T, Doi Y, Shimada K, Matsumoto A, Yamaguchi S, Hashimoto N, Senda M, Sakaguchi Y, Matsui I, Nakamoto K, Sera F, Hikoso S, Sakata Y, Isaka Y. Renoprotection by long-term low-dose tolvaptan in patients with heart failure and hyponatremia. ESC Heart Fail 2021; 8:4904-4914. [PMID: 34554640 PMCID: PMC8712924 DOI: 10.1002/ehf2.13507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/31/2021] [Accepted: 06/24/2021] [Indexed: 11/05/2022] Open
Abstract
AIMS In previous randomized controlled trials, the use of tolvaptan (TLV) at a fixed dose of 30 mg/day for 1 year did not provide renal benefits in patients with heart failure (HF). This retrospective, cohort study examined the renoprotective effects of long-term, flexible-dose, and lower-dose TLV use. METHODS AND RESULTS Tolvaptan users were defined as patients receiving TLV for at least 180 consecutive days or those who continued it until death, any cardiac events, or renal replacement therapy even if it was taken for <180 days. Of a total of 584 HF patients, 78 TLV users were identified. The median age, baseline B-type natriuretic peptide, and estimated glomerular filtration rate (eGFR) were 71 years, 243 pg/mL, and 54 mL/min/1.73 m2 , respectively. During follow-up (median, 461 days), TLV use (median average dose, 7.5 mg/day) was associated with frequent dose reductions of loop diuretics (incidence rate ratio [IRR], 1.5; 95% confidence interval [CI], 1.1-2.2), particularly in patients with serum sodium ≤135 mEq/L (IRR, 2.9; 95% CI, 1.5-5.7) (Pinteraction = 0.04). In a mixed effects model, propensity score (PS)-matched TLV users had higher eGFRs over time than PS-matched never-users (P < 0.01). The entire cohort analyses (N = 584) yielded similar results. The renal benefit of TLV in terms of annualized eGFR slope was more pronounced in patients with lower sodium levels (Pinteraction = 0.03). This effect modification was extinguished when patients who underwent a loop diuretic dose reduction during the follow-up period were excluded from the analysis. CONCLUSIONS Long-term, flexible-dose, and low-dose TLV use was associated with better renal function, particularly in hyponatremic HF, possibly due to its loop diuretic dose-sparing effect in the long term.
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Affiliation(s)
- Tatsufumi Oka
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takayuki Hamano
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan.,Department of Nephrology, Nagoya City University Graduate School of Medical Sciences, 1, Azakawasumi, Mizuho-cho, Mizuho-ku, Aichi, Nagoya, 467-8602, Japan
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yohei Doi
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Karin Shimada
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ayumi Matsumoto
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Satoshi Yamaguchi
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan.,Department of Internal Medicine, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Nobuhiro Hashimoto
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan.,Department of Kidney Disease and Hypertension, Osaka General Medical Center, Osaka, Japan
| | - Masamitsu Senda
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yusuke Sakaguchi
- Department of Inter-Organ Communication Research in Kidney Disease, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Isao Matsui
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kei Nakamoto
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Fusako Sera
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shungo Hikoso
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
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26
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Bhagra SK, Pettit S, Parameshwar J. Implantable left ventricular assist device: indications, eligibility and current outcomes. Heart 2021; 108:233-241. [PMID: 34099466 DOI: 10.1136/heartjnl-2020-317886] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Sai Kiran Bhagra
- Advanced Heart Failure and Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Stephen Pettit
- Advanced Heart Failure and Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Jayan Parameshwar
- Advanced Heart Failure and Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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Da Silveira Cavalcante L, Tessier SN. Zebrafish as a New Tool in Heart Preservation Research. J Cardiovasc Dev Dis 2021; 8:39. [PMID: 33917701 PMCID: PMC8068018 DOI: 10.3390/jcdd8040039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/05/2021] [Accepted: 04/07/2021] [Indexed: 12/25/2022] Open
Abstract
Heart transplantation became a reality at the end of the 1960s as a life-saving option for patients with end-stage heart failure. Static cold storage (SCS) at 4-6 °C has remained the standard for heart preservation for decades. However, SCS only allows for short-term storage that precludes optimal matching programs, requires emergency surgeries, and results in the unnecessary discard of organs. Among the alternatives seeking to extend ex vivo lifespan and mitigate the shortage of organs are sub-zero or machine perfusion modalities. Sub-zero approaches aim to prolong cold ischemia tolerance by deepening metabolic stasis, while machine perfusion aims to support metabolism through the continuous delivery of oxygen and nutrients. Each of these approaches hold promise; however, complex barriers must be overcome before their potential can be fully realized. We suggest that one barrier facing all experimental efforts to extend ex vivo lifespan are limited research tools. Mammalian models are usually the first choice due to translational aspects, yet experimentation can be restricted by expertise, time, and resources. Instead, there are instances when smaller vertebrate models, like the zebrafish, could fill critical experimental gaps in the field. Taken together, this review provides a summary of the current gold standard for heart preservation as well as new technologies in ex vivo lifespan extension. Furthermore, we describe how existing tools in zebrafish research, including isolated organ, cell specific and functional assays, as well as molecular tools, could complement and elevate heart preservation research.
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Affiliation(s)
- Luciana Da Silveira Cavalcante
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 2114, USA;
- Shriners Hospitals for Children, Boston, MA 2114, USA
| | - Shannon N. Tessier
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 2114, USA;
- Shriners Hospitals for Children, Boston, MA 2114, USA
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Krishnan A, Bigelow B, Hsu S, Gilotra NA, Sharma K, Choi CW, Kilic A. Decreased Nutritional Risk Index is associated with mortality after heart transplantation. Clin Transplant 2021; 35:e14253. [PMID: 33576056 DOI: 10.1111/ctr.14253] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/26/2021] [Accepted: 02/01/2021] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Validated scoring tools, such as the Nutritional Risk Index (NRI), can aid clinicians in quantifying the degree of malnourishment in patients prior to an operation. We evaluated the association between NRI and outcomes after heart transplantation. METHODS The United Network for Organ Sharing (UNOS) database was used to identify adult patients (age > 18) undergoing heart transplantation between 1987 and 2016. NRI was calculated and categorized into previously established groupings representing severity of malnutrition. Multivariate Cox proportional hazards modeling were used to assess the primary outcome of all-cause mortality. RESULTS A total of 25,236 patients were included in the analysis. Most patients (75.4%) were male. Malnourishment was absent (NRI ≥ 100) in 11,022 (44%) patients, while 2,898 (12%) were mildly malnourished (97.5 ≤ NRI < 100), 8,685 (34%) were moderately malnourished (83.5 ≤ NRI < 97.5), and 2,631 (10%) were severely malnourished (NRI < 83.5). Moderate-to-severe malnutrition was associated with increased mortality (HR = 1.18, p < .001, 95%CI: 1.13-1.24), and post-transplant renal failure requiring dialysis (OR: 1.13, p < .001, 95%CI: 1.03-1.23). CONCLUSION Malnourishment determined by NRI is independently associated with mortality and post-transplant dialysis after heart transplant. This is the largest study of NRI in heart transplant recipients.
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Affiliation(s)
- Aravind Krishnan
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Benjamin Bigelow
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven Hsu
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisha A Gilotra
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kavita Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chun Woo Choi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Yang Z, Han F, Liao T, Zheng H, Luo Z, Ma M, He J, Li L, Ye Y, Zhang R, Huang Z, Zhang Y, Sun Q. Artemisinin Attenuates Transplant Rejection by Inhibiting Multiple Lymphocytes and Prolongs Cardiac Allograft Survival. Front Immunol 2021; 12:634368. [PMID: 33717174 PMCID: PMC7943449 DOI: 10.3389/fimmu.2021.634368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 01/07/2021] [Indexed: 01/06/2023] Open
Abstract
Immunological rejection is an important factor resulting in allograft dysfunction, and more valid therapeutic methods need to be explored to improve allograft outcomes. Many researches have indicated that artemisinin and its derivative exhibits immunosuppressive functions, apart from serving as a traditional anti-malarial drug. In this assay, we further explored the therapeutic effects of artemisinin for transplant rejection in a rat cardiac transplantation model. We found that it markedly attenuated allograft rejection and histological injury and significantly prolonged the survival of allograft. Upon further exploring the mechanism, we demonstrated that artemisinin not only attenuated T cell-mediated rejection (TCMR) by reducing effector T cell infiltration and inflammatory cytokine secretion and increasing regulatory T cell infiltration and immunoregulatory cytokine levels, but also attenuated antibody-mediated rejection (ABMR) through inhibition of B cells activation and antibody production. Furthermore, artemisinin also reduced macrophage infiltration in allografts, which was determined to be important for TCMR and ABMR. Moreover, we demonstrated that artemisinin significantly inhibited the function of pure T cells, B cells, and macrophages in vitro. All in all, this study provide evidence that artemisinin significantly attenuates TCMR and ABMR by targeting multiple effectors. Therefore, this agent might have potential for use in clinical settings to protect against transplant rejection.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Zhengyu Huang
- Research Institute of Organ Transplantation, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yannan Zhang
- Research Institute of Organ Transplantation, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qiquan Sun
- Research Institute of Organ Transplantation, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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30
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Guimarães GV, Ribeiro F, Arthuso FZ, Castro RE, Cornelissen V, Ciolac EG. Contemporary review of exercise in heart transplant recipients. Transplant Rev (Orlando) 2021; 35:100597. [PMID: 33607426 DOI: 10.1016/j.trre.2021.100597] [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: 11/18/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 11/26/2022]
Abstract
Heart transplantation (HTx) is a therapeutic option for a selected group of patients with end-stage heart failure. Although secondary prevention including exercise therapy is recommended in the management of patients following HTx, little information is available on their metabolic and physiological consequences in HTx. Therefore, we aimed to conduct a contemporary review the effectiveness of exercise therapy on functional capacity, cardiovascular health and health-related quality of life for adult HTx patients. We searched the database MEDLINE for articles published between January 2015 and October 2020 and were able to include 6 studies involving 202 patients. Larger improvements in exercise capacity were seen after high-intensity interval training and in patients with evidence of cardiac reinnervation. Clinically relevant reductions were observed for daytime and 24 h ambulatory blood pressure after exercise training and following a single bout of aerobic exercise. Finally, limited data suggest that quality of life is higher in HTx patients following high-intensity training. In summary, the available evidence shows the potential for exercise as a vital treatment in patients following HTx. Yet, the scant data calls for more well-designed and adequately powered studies to support its effectiveness and to unravel optimal exercise characteristics, which would allow for more effective and person-tailored exercise prescription.
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Affiliation(s)
| | - Fernando Ribeiro
- School of Health Sciences and Institute of Biomedicine - iBiMED, University of Aveiro, Aveiro, Portugal
| | - Fernanda Zane Arthuso
- Department of Physical Education, School of Sciences, São Paulo State University (UNESP), Bauru, Brazil
| | - Rafael Ertner Castro
- Heart Institute, School of Medicine, University of São Paulo (USP), São Paulo, Brazil
| | | | - Emmanuel Gomes Ciolac
- Department of Physical Education, School of Sciences, São Paulo State University (UNESP), Bauru, Brazil
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31
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Wang F, Chen X, Li J, Wang D, Huang H, Li X, Bi Z, Peng Y, Zhang X, Li G, Wang J, Wang C, Fu Q, Liu L. Dose- and Time-Dependent Effects of Human Mesenchymal Stromal Cell Infusion on Cardiac Allograft Rejection in Mice. Stem Cells Dev 2021; 30:203-213. [PMID: 33371825 DOI: 10.1089/scd.2019.0300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Heart transplantation is the final life-saving therapeutic strategy for many end-stage heart diseases. Long-term immunosuppressive regimens are needed to prevent allograft rejection. Mesenchymal stromal cells (MSCs) have been shown as immunomodulatory therapy for organ transplantation. However, the effect of dose and timing of MSC treatment on heart transplantation has not yet been examined. In this study, we infused three doses (1 × 106, 2 × 106, or 5 × 106 cells) of human MSCs (hMSCs) to the recipient BALB/c mice before (7 days or 24 h) or after (24 h) receiving C57BL/6 cardiac transplants. We found that infusion of high dose hMSCs (5 × 106) at 24 h post-transplantation significantly prolonged the survival time of cardiac grafts. To delineate the underlying mechanism, grafts, spleens, and draining lymph nodes were harvested for analysis. Dose-dependent effect of hMSC treatment was shown in: (1) alleviation of International Society of Heart and Lung Transplantation (ISHLT) score in grafts; (2) reduction of the population of CD4+ and CD8+ T cells; (3) increase of regulatory T (Treg) cells; (4) and decrease of serum levels of inflammatory cytokines and donor-specific antibodies. Taken together, we showed timing critical and dose-dependent immunomodulatory effects of hMSC treatment against acute allograft rejection in a mouse model of heart transplantation.
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Affiliation(s)
- Feng Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Organ Transplant Center, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiaoyong Chen
- Center for Stem Cell Biology and Tissue Engineering, Sun Yat-sen University, Guangzhou, China
| | - Jun Li
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dong Wang
- Department of Clinical Laboratory, The First Affiliated Hospital, SunYat-sen University, Guangzhou, China
| | - Huiting Huang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xirui Li
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zirong Bi
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanwen Peng
- The Biotherapy Center, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoran Zhang
- Center for Stem Cell Biology and Tissue Engineering, Sun Yat-sen University, Guangzhou, China
| | - Gang Li
- Center for Stem Cell Biology and Tissue Engineering, Sun Yat-sen University, Guangzhou, China
| | - Jiali Wang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Changxi Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory on Organ Donation and Transplant Immunology, Guangzhou, China
| | - Qian Fu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Longshan Liu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory on Organ Donation and Transplant Immunology, Guangzhou, China
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32
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Campara M, Lourenco LM, Melaragno JI, Kaiser TE. Implications for body weight extremes in solid organ transplantation. Pharmacotherapy 2021; 41:44-58. [PMID: 33301647 DOI: 10.1002/phar.2493] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 11/19/2020] [Accepted: 12/01/2020] [Indexed: 12/17/2022]
Abstract
The pharmacokinetic profiles of medications are altered in overweight and underweight patients, but few studies have described these differences in patients with body mass index extremes. As solid organ transplant programs expand their candidate selection criteria to accommodate a growing population of patients with weight extremes, it has become imperative to understand and evaluate the impact weight extremes have on the pharmacokinetics of life-sustaining immunosuppression in this population. This review will describe pharmacokinetic and dosing considerations for weight extremes in solid organ transplant recipients, including changes following bariatric surgeries, non-pharmacologic and pharmacologic management strategies for weight loss and gain, and potential drug-drug interactions with popular weight management products.
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Affiliation(s)
- Maya Campara
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, 60612, USA
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33
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Oprzędkiewicz A, Mado H, Szczurek W, Gąsior M, Szyguła-Jurkiewicz B. Donor-recipient Matching in Heart Transplantation. Open Cardiovasc Med J 2020. [DOI: 10.2174/18741924020140100042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Heart transplantation remains the treatment of choice for end-stage Heart Failure (HF). Due to the shortage of organs for transplantation and the occurrence of perioperative complications, a key problem is donor matching, which should result in increased survival and improved quality of life for patients. The success of this procedure depends on various parameters such as gender, weight, ABO blood group and Human Leukocyte Antigen (HLA) system of both the recipient and the donor. Furthermore, non-HLA antigens may also be valuable in donor-recipient matching. The aim of this article is to summarize the recent knowledge on the impact of various factors on accurate donor-recipient matching to heart transplantation.
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Fritz NM, Stamminger T, Ramsperger-Gleixner M, Kuckhahn AV, Müller R, Weyand M, Heim C. Cytomegalovirus chemokine receptor M33 knockout reduces chronic allograft rejection in a murine aortic transplant model. Transpl Immunol 2020; 64:101359. [PMID: 33301898 DOI: 10.1016/j.trim.2020.101359] [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: 09/24/2020] [Revised: 12/03/2020] [Accepted: 12/03/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Numerous studies suggest that cytomegalovirus (CMV) infection may act as isolated risk factor in the development of cardiac allograft vasculopathy (CAV). Viral G protein-coupled receptors (GPCRs) are thought to contribute to the pathogenic changes associated with CMV infection. The aim of this study was to investigate the role of murine cytomegalovirus GPCR M33 in the development of CAV in a murine aortic allograft model. METHODS MHC I-mismatched aortas of C.B10 (H2b) mice were transplanted into BALB/c (H2d) recipients, which were either mock-infected, infected with wild type (WT) MCMV or MCMV with a deleted M33-receptor gene (delM33). Persistence of cytomegalovirus infection was confirmed by qPCR and by luciferase assay to ensure active viral replication. Grafts were harvested on days 21 and 37 for intragraft mRNA expression and histological analysis. RESULTS Active viral replication was demonstrated and MCMV presence was confirmed by PCR within spleen, liver, salivary glands, lung and the aortic transplant. Infection with delM33 resulted in significantly less intimal proliferation compared to WT-MCMV but more pronounced proliferation than in mock-infected allografts (32.19% [delM33] vs. 41.71% [WT-MCMV] vs. 24.33% [MCMV-]). Intragraft expression of most analyzed genes was significantly increased in infected mice. VCAM-1, ICAM-1, PDGFβ, CXCR3 and Granzyme B were distinctly less expressed in grafts of delM33 infected compared to WT infected mice. Cellular infiltration revealed reduced dendritic cells and T cells in grafts infected with delM33 compared to WT MCMV. CONCLUSIONS These data suggest that the MCMV encoded receptor M33 plays an important role as a viral effector mechanism contributing to the development of CAV in a murine aortic transplant model.
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Affiliation(s)
- Niklas M Fritz
- Department of Cardiac Surgery, Friedrich-Alexander University Erlangen-Nürnberg, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Thomas Stamminger
- Institute for Virology, University of Ulm, Albert-Einstein-Allee 11, 89081 Ulm, Germany
| | - Martina Ramsperger-Gleixner
- Department of Cardiac Surgery, Friedrich-Alexander University Erlangen-Nürnberg, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Annika V Kuckhahn
- Department of Cardiac Surgery, Friedrich-Alexander University Erlangen-Nürnberg, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Regina Müller
- Institute of Clinical and Molecular Virology, Friedrich-Alexander University Erlangen-Nürnberg, Schlossgarten 4, 91054 Erlangen, Germany
| | - Michael Weyand
- Department of Cardiac Surgery, Friedrich-Alexander University Erlangen-Nürnberg, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Christian Heim
- Department of Cardiac Surgery, Friedrich-Alexander University Erlangen-Nürnberg, Krankenhausstraße 12, 91054 Erlangen, Germany.
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35
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Chen YW, Wei J, Chen HL, Cheng CH, Hou IC. Developing a Heart Transplantation Self-Management Support Mobile Health App in Taiwan: Qualitative Study. JMIR Mhealth Uhealth 2020; 8:e18999. [PMID: 32812883 PMCID: PMC7468636 DOI: 10.2196/18999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/17/2020] [Accepted: 07/07/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Heart transplantation (HTx) is the most effective treatment for end-stage heart failure patients. After transplantation, patients face physiological, psychological, social, and other health care problems. Mobile health (mHealth) apps can change the delivery of conventional health care to ubiquitous care and improve health care quality. However, a dearth of mHealth apps exists for patients with HTx worldwide, including in Taiwan. OBJECTIVE The aim of this study was to investigate the information needed and to develop a preliminary framework for an mHealth app for post-HTx patients. METHODS A qualitative approach with individual in-depth interviews was conducted at a heart center in the regional hospital of northern Taiwan from June to November 2017. Patients that had undergone HTx and their health professionals were recruited for purposeful sampling. A semistructured interview guideline was used for individual interviews and transcribed. Thematic analysis was used for data analysis. RESULTS A total of 21 subjects, including 17 patients and 4 health professionals, were recruited for the study. The following five major themes were identified: reminding, querying, experience sharing, diet, and expert consulting. Minor themes included a desire to use the app with artificial intelligence and integration with professional management. CONCLUSIONS An intelligent mHealth app that addresses the five main themes and integrates the processes of using a mobile app could facilitate HTx self-management for Taiwanese patients.
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Affiliation(s)
- Yi-Wen Chen
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Jeng Wei
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Hwei-Ling Chen
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | | | - I-Ching Hou
- School of Nursing, National Yang-Ming University, Taipei, Taiwan
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Merlo M, Masè M, Cannatà A, Zaffalon D, Lardieri G, Limongelli G, Imazio M, Canepa M, Castelletti S, Bauce B, Biagini E, Livi U, Severini GM, Dal Ferro M, Marra MP, Basso C, Autore C, Sinagra G. Management of nonischemic-dilated cardiomyopathies in clinical practice: a position paper of the working group on myocardial and pericardial diseases of Italian Society of Cardiology. J Cardiovasc Med (Hagerstown) 2020; 21:927-943. [PMID: 32740436 DOI: 10.2459/jcm.0000000000001050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
: Nonischemic-dilated cardiomyopathy (NIDCM) is an entity that gathers extremely heterogeneous diseases. This awareness, although leading to continuous improvement in survival, has increased the complexity of NIDCM patients' management. Even though the endorsed 'red-flags' approach helps clinicians in pursuing an accurate etiological definition in clinical practice, it is not clear when and how peripheral centers should interact with referral centers with specific expertise in challenging scenarios (e.g. postmyocarditis and genetically determined dilated cardiomyopathy) and with easier access to second-line diagnostic tools and therapies. This position paper will summarize each step in NIDCM management, highlighting the multiple interactions between peripheral and referral centers, from first-line diagnostic workup and therapy to advanced heart failure management and long-term follow-up.
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Affiliation(s)
- Marco Merlo
- Cardiothoracovascular Department , Center for Diagnosis and Management of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste
| | - Marco Masè
- Cardiothoracovascular Department , Center for Diagnosis and Management of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste
| | - Antonio Cannatà
- Cardiothoracovascular Department , Center for Diagnosis and Management of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste
| | - Denise Zaffalon
- Cardiothoracovascular Department , Center for Diagnosis and Management of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste
| | - Gerardina Lardieri
- Cardiology Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Hospital of Gorizia and Monfalcone
| | - Giuseppe Limongelli
- Department of Translational Medical Sciences, Inherited and Rare Heart Disease, Vanvitelli Cardiology, University of Campania Luigi Vanvitelli, Caserta
| | - Massimo Imazio
- University Cardiology, A.O.U. Città della Salute e della Scienza di Torino, Torino
| | - Marco Canepa
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino - IRCCS Italian Cardiovascular Network.,Department of Internal Medicine, University of Genova, Genova
| | - Silvia Castelletti
- IRCCS Istituto Auxologico Italiano, Center for Cardiac Arrhythmias of Genetic Origin, Milan
| | - Barbara Bauce
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padova
| | - Elena Biagini
- Azienda Ospedaliero - Universitaria, Policlinico di Sant'Orsola, Cardiology Unit, Cardio-Thoracic-Vascular Department, Bologna, Italy
| | - Ugolino Livi
- Cardiothoracic Department, University Hospital of Udine, Udine
| | | | - Matteo Dal Ferro
- Cardiothoracovascular Department , Center for Diagnosis and Management of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste
| | - Martina Perazzolo Marra
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padova
| | - Cristina Basso
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padova
| | - Camillo Autore
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Gianfranco Sinagra
- Cardiothoracovascular Department , Center for Diagnosis and Management of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste
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Cheshire C, Bhagra CJ, Bhagra SK. A review of the management of patients with advanced heart failure in the intensive care unit. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:828. [PMID: 32793673 PMCID: PMC7396251 DOI: 10.21037/atm-20-1048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Despite progress in the medical and device therapy for heart failure (HF), the prognosis for those with advanced HF remains poor. Acute heart failure (AcHF) is the rapid development of, or worsening of symptoms and signs of HF typically leading to hospitalization. Whilst many HF decompensations are managed at a ward-based level, a proportion of patients require higher acuity care in the intensive care unit (ICU). Admission to ICU is associated with a higher risk of in-hospital mortality, and in those who fail to respond to standard supportive and medical therapy, a proportion maybe suitable for mechanical circulatory support (MCS). The optimal pre-operative management of advanced HF patients awaiting durable MCS or cardiac transplantation (CTx) is vital in improving both short and longer-term outcomes. This review will summarize the clinical assessment, hemodynamic profiling and management of the patient with AcHF in the ICU. The general principles of pre-surgical optimization encompassing individual systems (the kidneys, the liver, blood and glycemic control) will be discussed. Other factors impacting upon post-operative outcomes including nutrition and sarcopenia and pre-surgical skin decolonization have been included. Issues specific to durable MCS including the assessment of the right ventricle and strategies for optimization will also be discussed.
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Affiliation(s)
- Caitlin Cheshire
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Catriona Jane Bhagra
- Department of Cardiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sai Kiran Bhagra
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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Carvalho WDN, Alves Maria GDS, Gonçalves KC, Miranda AL, Moreira MDCV. Health-Related Quality of Life of Heart Transplant Recipients Living in a Developing Country. Transplant Proc 2020; 53:358-363. [PMID: 32620391 DOI: 10.1016/j.transproceed.2020.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 05/12/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Heart transplantation (HT) is the treatment for patients with end-stage heart failure (HF). It is hoped that the procedure increases both survival rates and the level of health-related quality of life (HRQoL), which may, however, be compromised by post-transplant complications. The objective of this study was to analyze the level of HRQoL in HT recipients and considered the influence of variables from social and clinical contexts. MATERIALS AND METHODS This is a cross-sectional study of HT recipients. The level of HRQoL was assessed by the World Health Organization Quality of Life-BREF (WHOQOL-BREF) questionnaire during outpatient consultation. RESULTS This study analyzed 186 HT recipients from a total of 192 eligible patients. The median level of HRQoL was ≥67.8 points in all domains of the WHOQOL-BREF questionnaire (physical, psychological, social relationships, and environment) and general score of perception of the level of quality of life (QoL) and health. Variables such as age, ethnicity, per capita income, time from last hospitalization, number of current medications, and number of hospitalizations after HT were significantly related to at least 1 domain of the WHOQOL-BREF. CONCLUSION In this study, HRQoL of HT recipients living in a developing country can be considered satisfactory given the high score obtained in all domains of WHOQOL-BREF and in the perception of the level of QoL and health.
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Affiliation(s)
| | | | | | | | - Maria Da Consolação Vieira Moreira
- School of Medicine, Federal University of Minas Gerais, Minas Gerais, Brazil; Clinics Hospital, Federal University of Minas Gerais, Minas Gerais, Brazil
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39
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Cantero-Pérez EM, Sayago I, Sobrino-Márquez JM, Rangel-Sousa D, Grande-Trillo A, Rezaei K, Adsuar-Gómez A. Impact of Preoperative Pulmonary Hypertension on Survival in Patients Undergoing Elective Heart Transplant. Transplant Proc 2020; 52:580-583. [PMID: 32057502 DOI: 10.1016/j.transproceed.2019.11.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 11/06/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) represents a marker of bad prognosis in left heart disease. Nonetheless, the effect on survival after heart transplant remains controversial. The objective was to study the impact of preoperative PAH on survival in patients undergoing elective heart transplant. METHODS A retrospective study of 173 transplant recipients was conducted at a single hospital from January 2009 to December 2018. Congenital etiology and emergent heart transplant were exclusion criteria as well as those patients without enough data in the hemodynamic study. Two groups were considered: A (without PAH) and B (with HTP). PAH was classified as mild (mean pulmonary arterial pressure [mPAP] 25-34 mm Hg, pulmonary vascular resistance [PVR] 2.5-3.4 Wood units and/or transpulmonary gradient [TPG] 13-16 mm Hg), moderate (mPAP 35-44 mm Hg, PVR 3.5-4.9 Wood units and/or TPG 17-19 mm Hg), and severe (mPAP > 44 mm Hg, PVR > 4.9 Wood units and/or TPG > 19 mm Hg). RESULTS A total of 102 patients were enrolled; 71.6% were male and average age was 52.3 (SD, 10.02) years. The main etiology was ischemic cardiomyopathy; 13.7% underwent previous heart operations. A total of 61 patients (59.8%) had PAH prior to heart transplant: 25 mild, 34 moderate, and 2 severe. Mean overall survival after transplant was 79.9 (SD, 5.68) months, without differences between the 2 groups (P = .82). One-month survival was 89% (the main cause of mortality was primary graft dysfunction), and 1-year survival was 78%. Four patients required mechanical circulatory support during early post-transplant period. CONCLUSIONS Preoperative PAH does not have a significant impact on survival in elective heart transplant.
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Affiliation(s)
- Eva María Cantero-Pérez
- Department of Cardiology, Heart Area, Clinical Management Unit, Virgen del Rocío University Hospital, Seville, Spain.
| | - Inés Sayago
- Department of Cardiology, Heart Area, Clinical Management Unit, Virgen del Rocío University Hospital, Seville, Spain
| | - José Manuel Sobrino-Márquez
- Department of Cardiology, Heart Area, Clinical Management Unit, Virgen del Rocío University Hospital, Seville, Spain
| | - Diego Rangel-Sousa
- Department of Cardiology, Heart Area, Clinical Management Unit, Virgen del Rocío University Hospital, Seville, Spain
| | - Antonio Grande-Trillo
- Department of Cardiology, Heart Area, Clinical Management Unit, Virgen del Rocío University Hospital, Seville, Spain
| | - Kambiz Rezaei
- Department of Cardiovascular Surgery, Heart Area, Clinical Management Unit, Virgen del Rocío University Hospital, Seville, Spain
| | - Alejandro Adsuar-Gómez
- Department of Cardiovascular Surgery, Heart Area, Clinical Management Unit, Virgen del Rocío University Hospital, Seville, Spain
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40
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Jha AK, Lata S. Kidney transplantation and cardiomyopathy: Concepts and controversies in clinical decision-making. Clin Transplant 2020; 34:e13795. [PMID: 31991012 DOI: 10.1111/ctr.13795] [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: 06/04/2019] [Revised: 08/21/2019] [Accepted: 01/24/2020] [Indexed: 11/30/2022]
Abstract
Increasing comorbidities and an aging population have led to a tremendous increase in the burden of both kidney and cardiac dysfunction. Concomitant cardiomyopathy exposes the patients with kidney disease to further physiological, hemodynamic, and pathologic alterations. Kidney transplantation imposes lesser anesthetic and surgical complexities compared to another solid organ transplant. The surgical decision-making remains an unsettled issue in these conditions. The surgical choices, techniques, and sequences in kidney transplant and cardiac surgery depend on the pathophysiological perturbations and perioperative outcomes. The absence of randomized controlled trials eludes us from suggesting definite management protocol in patients with end-stage kidney disease with cardiomyopathy. Nevertheless, in this review, we extracted data from published literature to understand the pathophysiologic interactions between end-stage renal diseases with cardiomyopathy and also proposed the management algorithm in this challenging scenario. The proposed management algorithm would ensure consensus across all stakeholders involved in decision-making. Our simplistic evidence-based approach would augur future randomized trials and would further ensure refinement in our management approach after the emergence of more definitive evidence.
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Affiliation(s)
- Ajay Kumar Jha
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Suman Lata
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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41
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Ribeiro AL, Otto CM. Heartbeat: Fixed dose combination drugs for hypertension. Heart 2019; 105:171-173. [PMID: 30647126 DOI: 10.1136/heartjnl-2018-314636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
| | - Catherine M Otto
- Division of Cardiology, University of Washington, Seattle, Washington, USA
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