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Nikolova AP, Kobashigawa JA. The EVOLVeD Role of Cholesterol-Lowering Therapies in Cardiac Allograft Vasculopathy. JACC. HEART FAILURE 2024:S2213-1779(24)00499-2. [PMID: 39023491 DOI: 10.1016/j.jchf.2024.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 05/22/2024] [Indexed: 07/20/2024]
Affiliation(s)
- Andriana P Nikolova
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA.
| | - Jon A Kobashigawa
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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2
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Holzhauser L, Norris M, Molina M, Chambers S, Sundaravel S, Rashed E, Gala K, Fallah T, Bittermann T, Reza N, Wang T, Atluri P, Goldberg L, McLean R, Peyster E. A heart transplant center experience with basiliximab induction strategies: A double edged sword? Clin Transplant 2024; 38:e15307. [PMID: 38567897 PMCID: PMC11129338 DOI: 10.1111/ctr.15307] [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: 12/23/2023] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND The use of induction immunosuppression for heart transplantation (HT) is debated given the uncertain benefit and potential risks of infection and malignancy. METHODS This is a retrospective single-center analysis of 475 consecutive HT recipients from 2003 to 2020 grouped by use of induction with basiliximab group (BG) and the no basiliximab group (NBG). Subgroup analysis by era compared pre-2016 standard-basiliximab (BX) induction and 2016-2020 with selective-BX use as part of a calcineurin-inhibitor-sparing regimen. RESULTS When adjusted for confounders (sex, age, PRA, eGFR), the BG was less likely to have acute cellular rejection (ACR) (OR.42, p < .001), but had more antibody mediated rejection (AMR) (OR 11.7, p < .001) and more cardiac allograft vasculopathy (CAV) (OR 3.8, p = .04). There was no difference between BG and NBG in the incidence of malignancies or infections. When stratified by era (pre-2016 vs. 2016-2020), ACR remained less common in the BG than the NBG (36% vs. 50%, p = .045) groups, while AMR remained more common (9.7 vs. 0% p = .005). There was no significant difference in conditional survival comparing pre-and post-2016 NBG (HR 2.20 (95% CI.75-6.43); however, both pre-2016 BG and post-2016 BG have significantly higher mortality (HR 2.37 [95% CI 1.02-5.50) and HR 2.69 (95% CI 1.08-6.71), p = .045 and.03, respectively]. CONCLUSION Basiliximab reduces the incidence of ACR but increases the risk of AMR, CAV, and may be associated with increased mortality. Mechanistic studies are needed to describe a potential T-cell-escape mechanism with enhanced humoral immunity.
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Affiliation(s)
- Luise Holzhauser
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maxwell Norris
- Department of Pharmacy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maria Molina
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Susan Chambers
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Swethika Sundaravel
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eman Rashed
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ketan Gala
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tara Fallah
- Department of Pharmacy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Therese Bittermann
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nosheen Reza
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Teresa Wang
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pavan Atluri
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lee Goldberg
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rhondalyn McLean
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eliot Peyster
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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3
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Rodenas-Alesina E, Aleksova N, Stubbs M, Foroutan F, Kozuszko S, Posada JD, McDonald M, Moayedi Y, Ross H, Dipchand A. Cardiac allograft vasculopathy and survival in pediatric heart transplant recipients transitioned to adult care. J Heart Lung Transplant 2024; 43:229-237. [PMID: 37704160 DOI: 10.1016/j.healun.2023.09.005] [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: 03/06/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is an important cause of mortality after pediatric heart transplantation (HT) but there is a paucity of data regarding its incidence and impact on survival in pediatric recipients transitioned to adult care. METHODS We conducted a retrospective review of consecutive pediatric HT patients from 1989 to 2017 at the Hospital for Sick Children who transitioned to adult care at ≥18 years at Toronto General Hospital. We evaluated the incidence of International Society of Heart and Lung Transplantation CAV grade ≥1 using competing risk models. We assessed the association between all-cause mortality and CAV using Cox proportional hazards and used Kaplan Meier methods to evaluate all-cause mortality stratified by CAV and transplant era (1989-2001, 2002-2017). RESULTS Ninety-six patients were transitioned to adult care by January 2022, of which 53 underwent repeat coronary angiography as adults. CAV was newly diagnosed in 49% patients after transition to adult care. The overall incidence of CAV was 3.9 cases per 100 person-years. There was no difference in the adjusted incidence of CAV according to transplant era (subdistribution hazard ratios = 1.17, 95% confidence interval (CI) 0.54-2.66). CAV was associated with a higher risk of death in the early era (hazard ratio (HR) 10.29, 95% CI 2.16-49.96), but not in the recent era (HR 1.61, 95% 0.35-7.47). CONCLUSIONS There is a role for continued CAV surveillance after the transition to adult care. The implications of diagnosing CAV after the transition to adult care require further study, particularly because the risk of death in pediatric HT recipients diagnosed with CAV in the more recent era may be attenuated compared to the earlier HT era.
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Affiliation(s)
| | - Natasha Aleksova
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Women's College Hospital, Toronto, Ontario, Canada.
| | - Michael Stubbs
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Farid Foroutan
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Stella Kozuszko
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Juan Duero Posada
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Michael McDonald
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Yasbanoo Moayedi
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Heather Ross
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Anne Dipchand
- Hospital for Sick Children, Toronto, Ontario, Canada
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4
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Opałka B, Żołnierczuk M, Grabowska M. Immunosuppressive Agents-Effects on the Cardiovascular System and Selected Metabolic Aspects: A Review. J Clin Med 2023; 12:6935. [PMID: 37959400 PMCID: PMC10647341 DOI: 10.3390/jcm12216935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 10/28/2023] [Accepted: 11/02/2023] [Indexed: 11/15/2023] Open
Abstract
The widespread use of immunosuppressive drugs makes it possible to reduce inflammation in autoimmune diseases, as well as prevent transplant rejection in organ recipients. Despite their key action in blocking the body's immune response, these drugs have many side effects. These actions primarily affect the cardiovascular system, and the incidence of complications in patients using immunosuppressive drugs is significant, being associated with a higher incidence of cardiovascular incidents such as myocardial infarction and stroke. This paper analyzes the mechanisms of action of commonly used immunosuppressive drugs and their impact on the cardiovascular system. The adverse effect of immunosuppressive drugs is associated with toxicity within the cardiovascular system, which may be a problem in the clinical management of patients after transplantation. Immunosuppressants act on the cardiovascular system in a variety of ways, including fibrosis and myocardial remodeling, endothelium disfunction, hypertension, atherosclerosis, dyslipidemia or hyperglycaemia, metabolic syndrome, and hyperuricemia. The use of multidrug protocols makes it possible to develop regimens that can reduce the incidence of cardiovascular events. A better understanding of their mechanism of action and the range of complications could enable physicians to select the appropriate therapy for a given patient, as well as to reduce complications and prolong life.
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Affiliation(s)
- Bianka Opałka
- Department of Histology and Developmental Biology, Faculty of Health Sciences, Pomeranian Medical University, 71-210 Szczecin, Poland;
| | - Michał Żołnierczuk
- Department of Plastic, Endocrine and General Surgery, Pomeranian Medical University, 72-010 Szczecin, Poland;
| | - Marta Grabowska
- Department of Histology and Developmental Biology, Faculty of Health Sciences, Pomeranian Medical University, 71-210 Szczecin, Poland;
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5
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Seguchi O, Azarbal B, Mirocha J, Youn JC, Passano E, Patel J, Kobashigawa J. Change in First-year Intravascular Ultrasound Results Predicts Adverse Events in Heart Transplant Recipients: Implications for Clinical Trial Endpoints. Transplantation 2023; 107:737-747. [PMID: 36358011 DOI: 10.1097/tp.0000000000004395] [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: 11/13/2022]
Abstract
BACKGROUND Heart transplantation (HTx) is an established therapeutic option for patients with advanced heart failure who are refractory to conventional guideline-directed treatments. This study aimed to reassess whether intravascular ultrasound variables could predict adverse events after HTx in the modern era. METHODS One hundred primary HTx recipients with available serial intravascular ultrasound examination results of the left anterior descending artery 4-8 wk and 1 y after HTx were enrolled, with an average follow-up duration of 5.7 y. The primary endpoint was a composite of all-cause death, nonfatal major adverse cardiac events, and angiographic cardiac allograft vasculopathy. RESULTS Forty-three patients developed primary endpoints. The baseline maximal intimal thickness was independently associated with the primary endpoint (hazard ratio, 8.24; 95% confidential interval [CI], 3.21-21.21; P < 0.001), and the optimal cutoff value was 0.64 mm. A change in the plaque atheroma volume in a proximal 20-mm segment from the left anterior descending artery bifurcation >1.05 mm 3 /mm (hazard ratio, 2.75; 95% CI, 1.28-5.89; P = 0.009) and a change in the first-year maximal intimal thickness >0.27 mm (hazard ratio, 2.63; 95% CI, 1.05-6.56; P = 0.04) were independent predictors of the primary endpoint 1 y after intravascular ultrasonography. CONCLUSIONS The aforementioned important clinical implications of intravascular ultrasound parameters are useful predictors of outcomes, which may be considered endpoints in modern clinical HTx trials.
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Affiliation(s)
- Osamu Seguchi
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Babak Azarbal
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
| | - James Mirocha
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jong-Chan Youn
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Elizabeth Passano
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
| | - Jignesh Patel
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
| | - Jon Kobashigawa
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
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6
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Bellumkonda L, Oikonomou EK, Hsueh C, Maulion C, Testani J, Patel J. The Impact of Induction Therapy on Mortality and Treated Rejection in Cardiac Transplantation: A Retrospective Study. J Heart Lung Transplant 2022; 41:482-491. [DOI: 10.1016/j.healun.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 12/07/2021] [Accepted: 01/01/2022] [Indexed: 11/27/2022] Open
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7
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Wang M, Patel NJ, Zhang X, Kransdorf EP, Azarbal B, Kittleson MM, Czer LSC, Kobashigawa JA, Patel JK. The effects of donor-specific antibody characteristics on cardiac allograft vasculopathy. Clin Transplant 2021; 35:e14483. [PMID: 34546613 DOI: 10.1111/ctr.14483] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/30/2021] [Accepted: 09/08/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) causes late graft dysfunction and post-transplant mortality. Currently, the effects of different donor-specific antibodies (DSA) on the severity of CAV remain unclear. METHOD We evaluated 526 adult heart transplant recipients at a single center between January 2010 and August 2015. Subjects were divided into those with DSA (n = 142) and those without DSA (n = 384, control). The DSA group was stratified into persistent DSA (n = 34), transient DSA (n = 105), 1:8 dilution DSA (n = 45), complement-binding (C1q) DSA (n = 36), Class I DSA (n = 37), and Class II DSA (n = 105). The primary outcome was the incidence of moderate-to-severe CAV (CAV 2/3) at 5-year follow-up. RESULTS Subjects with persistent DSA, 1:8 dilution DSA, and C1q DSA had higher incidence of CAV 2/3 compared the control group (17.6%, 13.3%, and 16.7% vs. 3.1%, respectively; P≤ .001). The incidence of CAV 2/3 between subjects with transient DSA and the control group was similar (2.8% vs. 3.1%; P = .888). Subjects with Class II DSA also had higher incidence of CAV 2/3 (7.6% vs. 3.1%; P = .039). CONCLUSION DSA that are persistent, 1:8 dilution positive, C1q positive, and Class II are associated with more severe grades of CAV. These DSA characteristics may prognosticate disease and warrant consideration for treatment.
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Affiliation(s)
- Maggie Wang
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nikhil J Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Xiaohai Zhang
- HLA and Immunogenetics Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Babak Azarbal
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michelle M Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Lawrence S C Czer
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jignesh K Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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8
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Tzani A, Van den Eynde J, Doulamis IP, Kuno T, Kampaktsis PN, Alvarez P, Briasoulis A. Impact of induction therapy on outcomes after heart transplantation. Clin Transplant 2021; 35:e14440. [PMID: 34296798 DOI: 10.1111/ctr.14440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 06/26/2021] [Accepted: 07/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Approximately 50% of heart transplant (HT) programs utilize induction therapy (IT) with interleukin-2 receptor antagonists (IL2RA) or polyclonal anti-thymocyte antibodies (ATG). METHODS Adult HT recipients were identified in the UNOS Registry between 2010 and 2020. We compared mortality between IT strategies with competing risk analysis. RESULTS A total of 28 634 HT recipients were included in the study (50.1% no IT, 21.3% ATG, 27.9% IL2RA, .7% alemtuzumab, .01% OKT3). Adjusted all-cause, 30 day and 1 year mortality were lower among those treated with IT than no IT (sub-hazard ratio [SHR] .87, 95% CI .79-.96, SHR .86, .76-.97, SHR .76, .63-.93, P = .007, respectively). In propensity score matching analysis IT was associated with lower 30-day and 1-year mortality. IL2RA had higher all-cause and 1-year mortality than ATG (SHR 1.41, 95% CI 1.23-1.69 and 1.55, 95% CI 1.29-1.88, respectively). Utilization of IT was associated with significantly lower risk of treated rejection at 1 year after HT compared with no IT (relative risk ratio [RRR] .79) and similarly ATG compared with IL2RA (RRR .51). CONCLUSION IT was associated with lower mortality and treated rejection episodes than no IT. IL2RA is the most used IT approach but ATG has lower risk of treated rejection and mortality.
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Affiliation(s)
- Aspasia Tzani
- Harvard Medical School, Department of Cardiac Surgery, Brigham and Women's Hospital Heart and Vascular Center, Boston, Massachusetts, USA
| | - Jef Van den Eynde
- The Johns Hopkins Hospital and School of Medicine, Helen B. Taussig Heart Center, Baltimore, USA.,Department of Cardiovascular Sciences KU Leuven, Leuven, Belgium
| | | | | | | | | | - Alexandros Briasoulis
- Division of Cardiovascular Medicine, University of Iowa Carver College of Medicine, Iowa, Iowa, USA.,National and Kapodistrian University of Athens, Greece
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9
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Rabbit Antithymocyte Globulin Induction in Heart Transplant Recipients at High Risk for Rejection. Ochsner J 2021; 21:133-138. [PMID: 34239371 PMCID: PMC8238107 DOI: 10.31486/toj.20.0024] [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] [Indexed: 11/25/2022] Open
Abstract
Background: Induction with lymphocyte-depleting antibodies may improve allograft outcomes in heart transplant recipients who are at high immunologic risk for rejection. Methods: We conducted a single-center retrospective cohort study that compared outcomes between adult patients receiving rabbit antithymocyte globulin (rATG) induction vs no induction from 2011 through 2017. Key exclusion criteria were patients who did not receive tacrolimus and mycophenolate and patients who did not meet high immunologic risk criteria. Results: A total of 50 patients were included in the analysis. At 1 year, the composite primary outcome of ≥2R rejection as defined by the International Society for Heart and Lung Transplantation, any treated rejection, development of cardiac allograft vasculopathy, or graft loss was not different between groups (P=0.474). Serious infections were also similar between groups (P=0.963). In accordance with institutional guidelines, prednisone exposure was decreased in the rATG induction group at 1 month (24.04 mg ± 13.74 vs 35.18 mg ± 16.95; P=0.014). Conclusion: These results suggest that while rATG induction does not improve heart allograft outcomes, it may enable reducing early corticosteroid exposure in patients at high immunologic risk.
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10
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Broch K, Gude E, Karason K, Dellgren G, Rådegran G, Gjesdal G, Gustafsson F, Eiskjær H, Lommi J, Pentikäinen M, Lemström KB, Andreassen AK, Gullestad L. Cholesterol lowering with EVOLocumab to prevent cardiac allograft Vasculopathy in De‐novo heart transplant recipients: Design of the randomized controlled EVOLVD trial. Clin Transplant 2020; 34:e13984. [DOI: 10.1111/ctr.13984] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 01/20/2023]
Affiliation(s)
- Kaspar Broch
- Department of Cardiology Oslo University Hospital, Rikshospitalet Oslo Norway
| | - Einar Gude
- Department of Cardiology Oslo University Hospital, Rikshospitalet Oslo Norway
| | - Kristjan Karason
- Transplant Institute Sahlgrenska University Hospital Gothenburg Sweden
| | - Göran Dellgren
- Transplant Institute Sahlgrenska University Hospital Gothenburg Sweden
| | - Göran Rådegran
- The Clinic for Heart Failure and Valvular Disease Skåne University Hospital Lund Sweden
- Lund University Lund Sweden
| | - Grunde Gjesdal
- The Clinic for Heart Failure and Valvular Disease Skåne University Hospital Lund Sweden
| | | | - Hans Eiskjær
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | - Jyri Lommi
- Helsinki University Hospital Heart and Lung Center Helsinki Finland
| | | | - Karl B. Lemström
- Helsinki University Hospital Heart and Lung Center Helsinki Finland
- University of Helsinki Helsinki Finland
| | - Arne K. Andreassen
- Department of Cardiology Oslo University Hospital, Rikshospitalet Oslo Norway
| | - Lars Gullestad
- Department of Cardiology Oslo University Hospital, Rikshospitalet Oslo Norway
- KG Jebsen Center for Cardiac Research University of Oslo Norway and Center for Heart Failure Research Oslo University Hospital Norway
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11
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Spitaleri G, Farrero Torres M, Sabatino M, Potena L. The pharmaceutical management of cardiac allograft vasculopathy after heart transplantation. Expert Opin Pharmacother 2020; 21:1367-1376. [PMID: 32401066 DOI: 10.1080/14656566.2020.1753698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Cardiac allograft vasculopathy (CAV) is a major limitation to long-term survival after heart transplantation. Its peculiar pathophysiology involves multifactorial pathways including immune-mediated and metabolic risk factors, which are associated with the development of specific pathological lesions. The often diffuse and chronic nature of the disease reduces the effectiveness of revascularization procedures, and pharmacological prevention of the disease is the sole therapeutic approach with some proven efficacy. AREAS COVERED In this article, after briefly outlining the risk factors for CAV, the authors revise the potential pharmacological approaches that may reduce the burden of CAV. While several therapies have shown convincing efficacy in terms of CAV prevention diagnosed by coronary imaging, very few have been reported to improve prognosis with any meaningful level of evidence. EXPERT OPINION The authors believe that a customizable approach is necessary for clinical practice given the currently available evidence. Furthermore, it is important, in the future, to address the glaring therapeutic gap of an effective treatment against donor-specific antibodies, whose effect on endothelial injury is currently one of the major mechanisms of CAV development and for which no pharmacological treatment is currently available.
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Affiliation(s)
- Giosafat Spitaleri
- Heart Failure and Heart Transplant Unit, Cardiovascular Institute, Hospital Clínic , Barcelona, Spain
| | - Marta Farrero Torres
- Heart Failure and Heart Transplant Unit, Cardiovascular Institute, Hospital Clínic , Barcelona, Spain
| | - Mario Sabatino
- Heart Failure and Heart Transplant Program, Bologna Academic Hospital , Bologna, Italy
| | - Luciano Potena
- Heart Failure and Heart Transplant Program, Bologna Academic Hospital , Bologna, Italy
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12
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Mallah SI, Atallah B, Moustafa F, Naguib M, El Hajj S, Bader F, Mehra MR. Evidence-based pharmacotherapy for prevention and management of cardiac allograft vasculopathy. Prog Cardiovasc Dis 2020; 63:194-209. [DOI: 10.1016/j.pcad.2020.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 03/17/2020] [Indexed: 01/08/2023]
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13
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Miller L, Birks E, Guglin M, Lamba H, Frazier OH. Use of Ventricular Assist Devices and Heart Transplantation for Advanced Heart Failure. Circ Res 2020; 124:1658-1678. [PMID: 31120817 DOI: 10.1161/circresaha.119.313574] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
There are only 2 treatments for the thousands of patients who progress to the most advanced form of heart failure despite the application of guideline-based medical therapy, use of ventricular assist devices and heart transplantation. There has been a great deal of progress in both of these therapies that have led to improved outcomes including significant improvement in survival and functional capacity. Heart transplantation offers the best short- and long-term survival for patients with end-stage heart failure, and the majority of these recipients achieve relatively limitless functional capacity for their age. However, the chronic shortage of available donors limits the number of recipients in the United States to an only 2500 patients/y or only a fraction of potential candidates. The significant improvement in outcomes now possible with durable ventricular assist devices has led to a significant increase in their use, which now exceeds the volume of heart transplants in the United States, with the greatest growth in use for those not considered to be candidates for heart transplantation, previously referred to as destination therapy. This article will review the substantial progress that has taken place for both of these life-saving treatment options, as well as the future directions.
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Affiliation(s)
- Leslie Miller
- From the Division of Cardiovascular Medicine, Texas Heart Institute, Houston (L.M., H.L., O.H.F.)
| | - Emma Birks
- Division of Cardiology, University of Louisville, KY (E.B.)
| | - Maya Guglin
- Division of Cardiology, University of Kentucky, Lexington (M.G.)
| | - Harveen Lamba
- From the Division of Cardiovascular Medicine, Texas Heart Institute, Houston (L.M., H.L., O.H.F.)
| | - O H Frazier
- From the Division of Cardiovascular Medicine, Texas Heart Institute, Houston (L.M., H.L., O.H.F.)
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14
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Impact of Induction Immunosuppression on Post-Transplant Outcomes of Patients Bridged with Contemporary Left Ventricular Assist Devices. ASAIO J 2020; 66:261-267. [PMID: 32101996 DOI: 10.1097/mat.0000000000001119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
For patients bridged to transplant (BTT) with left ventricular assist devices (LVAD), data regarding the use of induction immunosuppressive therapy remain limited. The objectives of the current study were to describe the current trends and clinical consequences of IT in patients BTT with LVAD. The United Network of Organ Sharing database was queried to identify adult, single-organ heart transplant recipients who were BTT with LVAD between 2008 and 2018. Propensity score matching was then used to balance clinical covariates between those patient who did and did not receive IT. The primary outcomes of interest were graft survival, hospitalization for rejection and infection, and freedom from transplant coronary artery disease (TCAD). In the overall cohort, 49.1% (n = 3,978) received IT, with basiliximab being the most commonly used agent followed by antithymocyte globulin. After propensity score matching, 4,388 patients (2,194 without induction and 2,194 with induction) were identified. Between those who did and did not receive IT, there was no significant difference in graft survival, freedom from hospitalization for rejection, and freedom from hospitalization for infection. Patients who received IT experienced increased freedom from TCAD (p = 0.004) with unadjusted hazard ratio of 0.81 (95% Cardiac Index: 0.70-0.93). For freedom from TCAD, antithymocyte globulin was associated with better outcomes than basiliximab (80.2% vs. 73.1% at 5 years, log rank p value = 0.004). In a sensitivity analysis, there was no significant increase in hospitalization for infection in those patients with an infected LVAD before transplant. Use of induction therapy in patients BTT with LVAD appears to be safe and feasible, without a significant increase in the risk of infection or rejection, even in those patients with pretransplant device-related infections. IT, particularly antithymocyte globulin, was associated with increased time to development of TCAD. Routine use of IT in patients BTT with LVAD may be considered, and further randomized control trials are warranted to further support these data.
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15
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Combined heart and kidney transplantation—Is there a protective effect against cardiac allograft vasculopathy using intravascular ultrasound? J Heart Lung Transplant 2019; 38:956-962. [DOI: 10.1016/j.healun.2019.06.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/14/2019] [Accepted: 06/16/2019] [Indexed: 11/20/2022] Open
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16
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Nikolova AP, Kobashigawa JA. Cardiac Allograft Vasculopathy: The Enduring Enemy of Cardiac Transplantation. Transplantation 2019; 103:1338-1348. [PMID: 31241553 DOI: 10.1097/tp.0000000000002704] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Cardiac allograft vasculopathy remains a major limiting factor in the long-term survival of the heart transplant recipient. Our understanding of its pathogenesis is continuously evolving as advances in imaging modalities have allowed a direct window into the natural history of the disease. Innovation in diagnostic modalities has spurred the proliferation of prognostic tools and biomarkers. And in parallel, pharmacological advances have emerged that have helped ameliorate the disease's progressive course.
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Affiliation(s)
- Andriana P Nikolova
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jon A Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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17
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Langstraat M, Musters KJS, Manintveld O, Masetti M, Potena L. Coronary artery disease in heart transplantation: new concepts for an old disease. Transpl Int 2018; 31:787-827. [DOI: 10.1111/tri.13141] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
| | | | | | - Marco Masetti
- Heart and Lung Transplant Program; Bologna University Hospital; Bologna Italy
| | - Luciano Potena
- Heart and Lung Transplant Program; Bologna University Hospital; Bologna Italy
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18
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Butts RJ, Dipchand AI, Sutcliffe D, Bano M, Dimas V, Morrow R, Das B, Kirk R. Comparison of basiliximab vs antithymocyte globulin for induction in pediatric heart transplant recipients: An analysis of the International Society for Heart and Lung Transplantation database. Pediatr Transplant 2018; 22:e13190. [PMID: 29878688 DOI: 10.1111/petr.13190] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2018] [Indexed: 11/28/2022]
Abstract
This study aims to compare 2 common induction strategies, basiliximab and ATG. Analysis of the ISHLT transplant registry was performed. The database was queried for pediatric heart transplants from January 1, 2000, to June 30, 2015, who had received induction with basiliximab or ATG. Primary end-point was graft survival. Secondary end-points included 1-year survival and 1-year conditional survival. There were 3158 heart transplants who received induction with basiliximab or ATG. The ATG cohort was younger, more likely to have congenital heart disease or be a retransplant, have a higher PRA, longer ischemic time, and been transplanted earlier in the study period (all P<.01). There was no difference in graft loss in the basiliximab cohort compared to the ATG cohort (HR 1.18 P=.06). On conditional 1-year survival analysis, basiliximab induction was associated with graft loss (HR=1.35 95% CI 1.1-1.7, P<.01), and in the propensity-matched cohort, the basiliximab cohort was more likely to experience rejection prior to discharge (P=.04). Infection prior to discharge was more common in the antithymocyte cohort. Induction with ATG is associated with improved late graft survival compared to basiliximab.
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Affiliation(s)
- Ryan J Butts
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anne I Dipchand
- Hospital for Sick Children, University of Toronto, Toronto, ON, USA
| | - David Sutcliffe
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Maria Bano
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vivian Dimas
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert Morrow
- Children's Medical Center of Dallas, Dallas, TX, USA
| | - Bibhuti Das
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Richard Kirk
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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Van Laecke S, Malfait T, Schepers E, Van Biesen W. Cardiovascular disease after transplantation: an emerging role of the immune system. Transpl Int 2018; 31:689-699. [PMID: 29611220 DOI: 10.1111/tri.13160] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 02/12/2018] [Accepted: 03/22/2018] [Indexed: 02/06/2023]
Abstract
Cardiovascular disease (CVD) after transplantation remains a major concern. Little is known about what drives the increased cardiovascular risk in transplant recipients apart from traditional risk factors. The immune system is involved in the pathogenesis of hypertension, atherosclerosis, and coronary artery disease in the general population. Recently, inhibition of interleukin 1 - β by canakinumab versus placebo decreased the incidence of cardiovascular events. Emerging evidence points to a role of adaptive cellular immunity in the development of CVD. Especially, expansion of pro-inflammatory and antiapoptotic cytotoxic CD4+ CD28null T cells is closely associated with incident CVD in various study populations including transplant recipients. The association of cytomegalovirus exposure with increased cardiovascular mortality might be explained by its capacity to upregulate these cytotoxic cells. Also, humoral immunity seems to be relevant for cardiovascular outcome in transplant recipients. Panel-reactive antibodies at baseline and donor-specific antibodies are independently associated with poor cardiovascular outcome after kidney transplantation. Cardiovascular effects of immunosuppressive drugs and statins do not only imply indirect positive or negative effects on traditional cardiovascular risk factors but also intrinsic immunological effects. How immunosuppressive drugs modify atherosclerosis largely remains elusive.
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Affiliation(s)
| | - Thomas Malfait
- Renal Division, Ghent University Hospital, Ghent, Belgium
| | - Eva Schepers
- Renal Division, Ghent University Hospital, Ghent, Belgium
| | - Wim Van Biesen
- Renal Division, Ghent University Hospital, Ghent, Belgium
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20
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Risk stratification to determine the impact of induction therapy on survival, rejection and adverse events after pediatric heart transplant: A multi-institutional study. J Heart Lung Transplant 2018; 37:458-466. [DOI: 10.1016/j.healun.2017.05.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 05/04/2017] [Accepted: 05/09/2017] [Indexed: 11/19/2022] Open
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22
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Ariyamuthu VK, Amin AA, Drazner MH, Araj F, Mammen PPA, Ayvaci M, Mete M, Ozay F, Ghanta M, Mohan S, Mohan P, Tanriover B. Induction regimen and survival in simultaneous heart-kidney transplant recipients. J Heart Lung Transplant 2017; 37:587-595. [PMID: 29198930 DOI: 10.1016/j.healun.2017.11.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/03/2017] [Accepted: 11/13/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Induction therapy in simultaneous heart-kidney transplantation (SHKT) is not well studied in the setting of contemporary maintenance immunosuppression consisting of tacrolimus (TAC), mycophenolic acid (MPA), and prednisone (PRED). METHODS We analyzed the Organ Procurement and Transplant Network registry from January 1, 2000, to March 3, 2015, for recipients of SHKT (N = 623) maintained on TAC/MPA/PRED at hospital discharge. The study cohort was further stratified into 3 groups by induction choice: induction (n = 232), rabbit anti-thymoglobulin (r-ATG; n = 204), and interleukin-2 receptor-α (n = 187) antagonists. Survival rates were estimated using the Kaplan-Meier estimator. Multivariable inverse probability weighted Cox proportional hazard regression models were used to assess hazard ratios associated with post-transplant mortality as the primary outcome. The study cohort was censored on March 4, 2016, to allow at least 1-year of follow-up. RESULTS During the study period, the number of SHKTs increased nearly 5-fold. The Kaplan-Meier survival curve showed superior outcomes with r-ATG compared with no induction or interleukin-2 receptor-α induction. Compared with the no-induction group, an inverse probability weighted Cox proportional hazard model showed no independent association of induction therapy with the primary outcome. In sub-group analysis, r-ATG appeared to lower mortality in sensitized patients with panel reactive antibody of 10% or higher (hazard ratio, 0.19; 95% confidence interval, 0.05-0.71). CONCLUSION r-ATG may provide a survival benefit in SHKT, especially in sensitized patients maintained on TAC/MPA/PRED at hospital discharge.
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Affiliation(s)
| | - Alpesh A Amin
- Division of, Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mark H Drazner
- Division of, Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Faris Araj
- Division of, Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Pradeep P A Mammen
- Division of, Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mehmet Ayvaci
- Information Systems, School of Management, University of Texas at Dallas, Dallas, Texas
| | - Mutlu Mete
- Department of Computer Science, Texas A&M University-Commerce, Commerce, Texas
| | - Fatih Ozay
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mythili Ghanta
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sumit Mohan
- Division of Nephrology, Columbia University Medical Center, New York, New York
| | - Prince Mohan
- Division of Nephrology, Geisinger Medical Center, Danville, Pennnsylvania
| | - Bekir Tanriover
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
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Broch K, Gude E, Andreassen AK, Gullestad L. Newer Immunosuppression and Strategies on the Horizon in Heart Transplantation. CURRENT TRANSPLANTATION REPORTS 2017. [DOI: 10.1007/s40472-017-0159-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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24
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Cheng R, Kransdorf EP, Wei J, Patel JK, Kobashigawa JA, Azarbal B. Angiogenesis on coronary angiography is a marker for accelerated cardiac allograft vasculopathy as assessed by intravascular ultrasound. Clin Transplant 2017; 31. [PMID: 28786501 DOI: 10.1111/ctr.13069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Errant neovascularization and coronary artery fistulae (CAF) are frequently observed after cardiac transplantation. The relationship between angiographic neovascularization/CAF and coronary plaque progression is unknown. METHODS Angiography and intravascular ultrasound were routinely performed at 4-6 weeks and 1-year post-transplant. Pts were divided into three groups: no angiographic angiogenesis (Group 1), neovascularization only (Group 2), and CAF (Group 3). First-year changes in maximal intimal thickness (MIT), maximal intimal area (MIA), and percent atheroma volume (PAV) were compared between groups. RESULTS The 106 pts were included, 40/106 in Group 1, 42/106 in Group 2, and 24/106 in Group 3. Respectively, first-year ΔMIT was 0.14 ± 0.13 mm, 0.32 ± 0.26 mm, and 0.50 ± 0.34 mm, P < .001. ΔMIA was 0.6 ± 0.6 mm2 , 1.7 ± 1.8 mm2 , and 3.0 ± 2.6 mm2 , P < .001. ΔPAV was 2.3 ± 2.5%, 6.0 ± 5.1%, and 9.6 ± 9.0%, P < .001. Rapid plaque progression occurred in 1/40 (2.5%) pts in Group 1, 12/42 (28.6%) in Group 2, and 12/24 (50%) in Group 3, P < .001. Multivariate analysis identified both antithymocyte globulin and presence of CAF as independently associated with rapid plaque progression: OR 0.29 (P = .038) and 4.04 (P = .014). CONCLUSION Neovascularization and CAF are commonly present on surveillance angiography after cardiac transplantation and may signify amplified angiogenesis. Their presence is associated with accelerated coronary plaque progression by IVUS.
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Affiliation(s)
| | | | - Janet Wei
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
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25
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Vega E, Schroder J, Nicoara A. Postoperative management of heart transplantation patients. Best Pract Res Clin Anaesthesiol 2017; 31:201-213. [PMID: 29110793 DOI: 10.1016/j.bpa.2017.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 06/01/2017] [Accepted: 06/16/2017] [Indexed: 01/17/2023]
Abstract
Heart transplant recipients are at risk for a number of post-transplantation complications such as graft dysfunction, rejection, and infection. The rates of many complications are decreasing over time, and prognosis is improving. However, these patients continue to experience significant morbidity and mortality. This review focuses on the optimal management of heart transplant recipients in the postoperative period, based on current knowledge. More information is needed about the best ways to predict, prevent, and treat primary graft dysfunction, right ventricular failure, and cellular and antibody-mediated rejection.
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Affiliation(s)
- Eleanor Vega
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
| | - Jacob Schroder
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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26
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Ruan V, Czer LSC, Awad M, Kittleson M, Patel J, Arabia F, Esmailian F, Ramzy D, Chung J, De Robertis M, Trento A, Kobashigawa JA. Use of Anti-Thymocyte Globulin for Induction Therapy in Cardiac Transplantation: A Review. Transplant Proc 2017; 49:253-259. [PMID: 28219580 DOI: 10.1016/j.transproceed.2016.11.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 11/16/2016] [Indexed: 01/20/2023]
Abstract
The most common causes of death after heart transplantation (HTx) include acute rejection and multi-organ failure in the early period and malignancy and cardiac allograft vasculopathy (CAV) in the late period. Polyclonal antibody preparations such as rabbit anti-thymocyte globulin (ATG) may reduce early acute rejection and the later occurrence of CAV after HTx. ATG therapy depletes T cells, modulates adhesion and cell-signaling molecules, interferes with dendritic cell function, and induces B-cell apoptosis and regulatory and natural killer T-cell expansion. Evidence from animal studies and from retrospective clinical studies in humans indicates that ATG can be used to delay calcineurin inhibitor (CNI) exposure after HTx, thus benefiting renal function, and to reduce the incidence of CAV and ischemia-reperfusion injury in the transplanted heart. ATG may reduce de novo antibody production after HTx. ATG does not appear to increase cytomegalovirus infection rates with longer prophylaxis (6-12 months). In addition, ATG may reduce the risk of lymphoproliferative disease and does not appear to confer an additive effect on acquiring lymphoma after HTx. Randomized, controlled trials may provide stronger evidence of ATG association with patient survival, graft rejection, renal protection through delayed CNI initiation, as well as other benefits. It can also help establish optimal dosing and patient criteria to maximize treatment benefits.
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Affiliation(s)
- V Ruan
- Division of Cardiology, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - L S C Czer
- Division of Cardiology, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California.
| | - M Awad
- Division of Cardiology, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - M Kittleson
- Division of Cardiology, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - J Patel
- Division of Cardiology, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - F Arabia
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - F Esmailian
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - D Ramzy
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - J Chung
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - M De Robertis
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - A Trento
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - J A Kobashigawa
- Division of Cardiology, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
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27
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Kransdorf EP, Loghmanpour NA, Kanwar MK, Temkit MH, Stehlik J. Prediction model for cardiac allograft vasculopathy: Comparison of three multivariable methods. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12925] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Evan P. Kransdorf
- Cedars-Sinai Heart Institute; Cedars-Sinai Medical Center; Los Angeles CA USA
| | | | - Manreet K. Kanwar
- Cardiovascular Institute; Allegheny General Hospital; Pittsburgh PA USA
| | - M'hamed H. Temkit
- Division of Health Sciences Research; Mayo Clinic Arizona; Scottsdale AZ USA
| | - Josef Stehlik
- Division of Cardiovascular Medicine; University of Utah School of Medicine; Salt Lake City UT USA
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28
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Okada K, Fearon WF, Luikart H, Kitahara H, Otagiri K, Tanaka S, Kimura T, Yock PG, Fitzgerald PJ, Yeung AC, Valantine HA, Khush KK, Honda Y. Attenuated-Signal Plaque Progression Predicts Long-Term Mortality After Heart Transplantation: IVUS Assessment of Cardiac Allograft Vasculopathy. J Am Coll Cardiol 2016; 68:382-92. [PMID: 27443435 PMCID: PMC4959008 DOI: 10.1016/j.jacc.2016.05.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 04/04/2016] [Accepted: 05/03/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although cardiac allograft vasculopathy (CAV) is typically characterized by diffuse coronary intimal thickening with pathological vessel remodeling, plaque instability may also play an important role in CAV. Previous studies of native coronary atherosclerosis have demonstrated associations between attenuated-signal plaque (ASP), plaque instability, and adverse clinical events. OBJECTIVES This study's aim was to characterize the association between ASP and long-term mortality post-heart transplantation. METHODS In 105 heart transplant recipients, serial (baseline and 1-year post-transplant) intravascular ultrasound was performed in the first 50 mm of the left anterior descending artery. The ASP score was calculated by grading the measured angle of attenuation from grades 0 to 4 (specifically, 0°, 1° to 90°, 91° to 180°, 181° to 270°, and >270°) at 1-mm intervals. The primary endpoint was all-cause death or retransplantation. RESULTS At 1-year post-transplant, 10.5% of patients demonstrated ASP progression (newly developed or increased ASP). Patients with ASP progression had a higher incidence of acute cellular rejection during the first year (63.6% vs. 22.3%; p = 0.006) and tendency for greater intimal growth (percent intimal volume: 9.2 ± 9.3% vs. 4.4 ± 5.3%; p = 0.07) than those without. Over a median follow-up of 4.6 years, there was a significantly lower event-free survival rate in patients with ASP progression at 1-year post-transplant compared with those without. In contrast, maximum intimal thickness did not predict long-term mortality. CONCLUSIONS ASP progression appears to reflect chronic inflammation related to acute cellular rejection and is an independent predictor of long-term mortality after heart transplantation. Serial assessments of plaque instability may enhance identification of high-risk patients who may benefit from closer follow-up and targeted medical therapies.
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Affiliation(s)
- Kozo Okada
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - William F Fearon
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Helen Luikart
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Hideki Kitahara
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Kyuhachi Otagiri
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Shigemitsu Tanaka
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Takumi Kimura
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Paul G Yock
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Peter J Fitzgerald
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Alan C Yeung
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Hannah A Valantine
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Yasuhiro Honda
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California.
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