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Bollano E, Andreassen AK, Eiskjaer H, Gustafsson F, Rådegran G, Gude E, Gullestad L, Broch K, Halden TAS, Karason K, Bartfay SE, Bergh N. Long-term follow-up of the randomized, prospective Scandinavian heart transplant everolimus de novo study with early calcineurin inhibitors avoidance (SCHEDULE) trial. J Heart Lung Transplant 2024:S1053-2498(24)01732-7. [PMID: 39038562 DOI: 10.1016/j.healun.2024.07.002] [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: 12/12/2023] [Revised: 05/08/2024] [Accepted: 07/03/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND Early substitution of calcineurin inhibitor (CNI) with mammalian target of rapamycin inhibitors has been shown to improve kidney function and reduce intimal hyperplasia in heart transplant (HTx) recipients but data on long-term outcome of such a regime are still sparse. METHODS In the SCHEDULE trial, 115 de novo HTx recipients were randomized to (1) everolimus with reduced exposure of CNI followed by CNI withdrawal at week 7-11 post-transplant or (2) standard-exposure with CNI. Both groups received mycophenolate mofetil and corticosteroids. Herein we report on the 10-12-year long-term follow-up of the study. RESULTS A total of 78 patients attended the follow-up visit at a median time of 11 years post-transplant. In the everolimus intention to treat (ITT) group 87.5% (35/40 patients) still received everolimus and in the CNI ITT group 86.8% (33/38) still received CNI. Estimated glomerular filtration rate (eGFR) (least square mean (95% CI)) at the 10-12 years visit was 82.7 (74.2-91.1) ml/min/1.73 m2 and 61.0 (52.3-69.7) ml/min/1.73 m2 in the everolimus and CNI group, respectively (p < 0.001). Graft function measured by ejection fraction, ECG, NT-proBNP and drug safety were comparable between groups. During the study period there was a total of 28 deaths, but there was no difference in survival between the everolimus and the CNI group (aHR 0.61 (95% CI 0.29-1.30) p = 0.20). For the composite endpoint of death, re-transplantation, myocardial infarction, PCI, dialysis, kidney transplantation or cancer no between group differences were found (aHR 1.0 (95% CI 0.57-1.77) p = 0.99). CONCLUSIONS De novo HTx patients randomized to everolimus and low dose CNI followed by CNI free therapy sustained significantly better long-term kidney function than patients randomized to standard therapy. The graft function at 10-12 years was similar in both groups and there was no difference in survival.
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Affiliation(s)
- Entela Bollano
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Transplantation, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Arne K Andreassen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Hans Eiskjaer
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Göran Rådegran
- Section for Heart Failure and Valvular Disease, Skåne University Hospital and Department of Clinical Sciences, Cardiology, Lund University, Lund, Sweden
| | - Einar Gude
- 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, Oslo, Norway
| | - Kaspar Broch
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway; KG Jebsen Center for Cardiac Research, University of Oslo, Oslo, Norway
| | | | - Kristjan Karason
- Department of Transplantation, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sven-Erik Bartfay
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Transplantation, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Niklas Bergh
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Qin Y, Shao B, Ren SH, Ye K, Qin H, Wang HD, Sun C, Zhu Y, Wang Z, Zhang J, Li X, Wang H. Interleukin-37 contributes to endometrial regenerative cell-mediated immunotherapeutic effect on chronic allograft vasculopathy. Cytotherapy 2024; 26:299-310. [PMID: 38159090 DOI: 10.1016/j.jcyt.2023.12.004] [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: 05/19/2023] [Revised: 11/26/2023] [Accepted: 12/12/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND AIMS Chronic allograft vasculopathy (CAV) remains a predominant contributor to late allograft failure after organ transplantation. Several factors have already been shown to facilitate the progression of CAV, and there is still an urgent need for effective and specific therapeutic approaches to inhibit CAV. Human mesenchymal-like endometrial regenerative cells (ERCs) are free from the deficiencies of traditional invasive acquisition methods and possess many advantages. Nevertheless, the exact immunomodulation mechanism of ERCs remains to be elucidated. METHODS C57BL/6 (B6) mouse recipients receiving BALB/c mouse donor abdominal aorta transplantation were treated with ERCs, negative control (NC)-ERCs and interleukin (IL)-37-/-ERCs (ERCs with IL-37 ablation), respectively. Pathologic lesions and inflammatory cell infiltration in the grafts, splenic immune cell populations, circulating donor-specific antibody levels and cytokine profiles were analyzed on postoperative day (POD) 40. The proliferative capacities of Th1, Th17 and Treg subpopulations were assessed in vitro. RESULTS Allografts from untreated recipients developed typical pathology features of CAV, namely endothelial thickening, on POD 40. Compared with untreated and IL-37-/-ERC-treated groups, IL-37-secreting ERCs (ERCs and NC-ERCs) significantly reduced vascular stenosis, the intimal hyperplasia and collagen deposition. IL-37-secreting ERCs significantly inhibited the proliferation of CD4+T cells, reduced the proportions of Th1 and Th17 cells, but increased the proportion of Tregs in vitro. Furthermore, in vitro results also showed that IL-37-secreting ERCs significantly inhibited Th1 and Th17 cell responses, abolished B-cell activation, diminished donor-specific antibody production and increased Treg proportions. Notably, IL-37-secreting ERCs remarkably downregulated the levels of pro-inflammatory cytokines (interferon-γ, tumor necrosis factor-α, IL-1β, IL-6 and IL-17A) and increased IL-10 levels in transplant recipients. CONCLUSIONS The knockdown of IL-37 dramatically abrogates the therapeutic ability of ERCs for CAV. Thus, this study highlights that IL-37 is indispensable for ERC-mediated immunomodulation for CAV and improves the long-term allograft acceptance.
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Affiliation(s)
- Yafei Qin
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China; Department of Vascular Surgery, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, PR China.
| | - Bo Shao
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China; Tianjin General Surgery Institute, Tianjin Medical University General Hospital, Tianjin, PR China.
| | - Shao-Hua Ren
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China; Tianjin General Surgery Institute, Tianjin Medical University General Hospital, Tianjin, PR China.
| | - Kui Ye
- Department of Vascular Surgery, Tianjin Fourth Central Hospital, The Fourth Central Clinical College, Tianjin Medical University, Tianjin, PR China.
| | - Hong Qin
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China; Tianjin General Surgery Institute, Tianjin Medical University General Hospital, Tianjin, PR China.
| | - Hong-da Wang
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China; Tianjin General Surgery Institute, Tianjin Medical University General Hospital, Tianjin, PR China.
| | - Chenglu Sun
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China; Tianjin General Surgery Institute, Tianjin Medical University General Hospital, Tianjin, PR China.
| | - Yanglin Zhu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China; Tianjin General Surgery Institute, Tianjin Medical University General Hospital, Tianjin, PR China.
| | - Zhaobo Wang
- School of Basic Medical Sciences, Tianjin Medical University, Tianjin, PR China.
| | - Jingyi Zhang
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China; Tianjin General Surgery Institute, Tianjin Medical University General Hospital, Tianjin, PR China.
| | - Xiang Li
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China; Tianjin General Surgery Institute, Tianjin Medical University General Hospital, Tianjin, PR China.
| | - Hao Wang
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China; Tianjin General Surgery Institute, Tianjin Medical University General Hospital, Tianjin, PR China.
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3
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El-Andari R, Bozso SJ, Fialka NM, Kang JJH, MacArthur RGG, Meyer SR, Freed DH, Nagendran J. Coronary Artery Revascularization in Heart Transplant Patients: A Systematic Review and Meta-analysis. Cardiology 2022; 147:348-363. [PMID: 35500568 DOI: 10.1159/000524781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 02/02/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is the primary cause of late mortality after heart transplantation (HTx). We look to provide a comprehensive review of contemporary revascularization strategies in CAV. METHODS PubMed and Web of Science were systematically searched by 3 authors. 1,870 articles were initially screened and 24 were included in this review. RESULTS PCI is the main revascularization technique utilized in CAV. The pooled estimates for restenosis significantly favored DES over BMS (OR 4.26; 95% CI, 2.54-7.13; p< 0.00001; I2=4%). There was insufficient data to quantitatively compare mortality following DES versus BMS. There was no difference in short-term mortality between CABG and PCI. In-hospital mortality was 0.0% for CABG and ranged from 0.0-8.34% for PCI. 1-year mortality was 8.0% for CABG and 5.0-25.0% for PCI. CABG had a potential advantage at 5 years. 5-year mortality was 17.0% for CABG and ranged from 14-40.4% following PCI. Select measures of postoperative morbidity trended towards superior outcomes for CABG. CONCLUSIONS In CAV, PCI is the primary revascularization strategy utilized, with DES exhibiting superiority to BMS regarding postoperative morbidity. Further investigation into outcomes following CABG in CAV is required to conclusively elucidate the superior management strategy in CAV.
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Affiliation(s)
- Ryaan El-Andari
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Sabin J Bozso
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Nicholas M Fialka
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jimmy J H Kang
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Roderick G G MacArthur
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Steven R Meyer
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Darren H Freed
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Jeevan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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4
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Nelson LM, Andreassen AK, Arora S, Andersson B, Gude E, Eiskjaer H, Rådegran G, Dellgren G, Gullestad L, Gustafsson F. Mild acute cellular rejection and development of cardiac allograft vasculopathy assessed by intravascular ultrasound and coronary angiography in heart transplant recipients-a SCHEDULE trial substudy. Transpl Int 2020; 33:517-528. [PMID: 31958178 DOI: 10.1111/tri.13577] [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: 08/14/2019] [Revised: 09/20/2019] [Accepted: 01/13/2020] [Indexed: 12/18/2022]
Abstract
To evaluate the association between mild acute cellular rejection (ACR) and the development of cardiac allograft vasculopathy (CAV) after heart transplantation (HTx). Substudy of the SCHEDULE trial (n = 115), where de novo HTx recipients were randomized to (i) everolimus with early CNI elimination or (ii) CNI-based immunosuppression. Seventy-six patients (66%) were included based on matched intravascular ultrasound (IVUS) examinations at baseline and year 3 post-HTx. Biopsy-proven ACR within year 1 post-HTx was recorded and graded (1R, 2R, 3R). Development of CAV was assessed by IVUS and coronary angiography at year 3 post-HTx. Median age was 53 years (45-61), and 71% were male. ACR was recorded in 67%, and patients were grouped by rejection profile: no ACR (33%), only 1R (42%), and ≥2R (25%). Median ∆MIT (maximal intimal thickness)BL-3Y was not significantly different between groups (P = 0.84). The incidence of CAV was 49% by IVUS and 26% by coronary angiography with no significant differences between groups. No correlation was found between number of 1R and ∆MITBL-3Y (r = -0.025, P = 0.83). The number of 1R was not a significant predictor of ∆MITBL-3Y (P = 0.58), and no significant interaction with treatment was found (P = 0.98). The burden of mild ACR was not associated with CAV development.
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Affiliation(s)
- Laerke Marie Nelson
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Satish Arora
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,K.G. Jebsen Cardiac Research Centre and Center for Heart Failure Research, Oslo, Norway
| | - Bert Andersson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Einar Gude
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Hans Eiskjaer
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Göran Rådegran
- The Section for Heart Failure and Valvular Disease, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden
| | - Göran Dellgren
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,K.G. Jebsen Cardiac Research Centre and Center for Heart Failure Research, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Finn Gustafsson
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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5
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Arora S, Andreassen AK, Karason K, Gustafsson F, Eiskjær H, Bøtker HE, Rådegran G, Gude E, Ioanes D, Solbu D, Dellgren G, Ueland T, Aukrust P, Gullestad L. Effect of Everolimus Initiation and Calcineurin Inhibitor Elimination on Cardiac Allograft Vasculopathy in De Novo Heart Transplant Recipients. Circ Heart Fail 2019; 11:e004050. [PMID: 30354362 DOI: 10.1161/circheartfailure.117.004050] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Cardiac allograft vasculopathy (CAV) limits survival after heart transplantation, and the effect of different immunosuppressive regimens on CAV is not fully understood. The randomized SCHEDULE trial (Scandinavian Heart Transplant Everolimus De Novo Study With Early Calcineurin Inhibitors Avoidance) evaluated whether initiation of the proliferation signal inhibitor everolimus and early cyclosporine elimination can reduce CAV development. Methods and Results The SCHEDULE trial was a multicenter Scandinavian trial, where 115 de novo heart transplantation recipients were randomized to everolimus with complete cyclosporine withdrawal 7 to 11 weeks after heart transplantation or standard cyclosporine-based immunosuppression. Seventy-six (66%) patients had matched intravascular ultrasound examinations at baseline and 12 and 36 months. Intravascular ultrasound analysis evaluated maximal intimal thickness, percent atheroma volume, and total atheroma volume. Qualitative plaque analysis using virtual histology assessed fibrous, fibrofatty, and calcified tissue as well as necrotic core. Serum inflammatory markers were measured in parallel. The everolimus group (n=37) demonstrated significantly reduced CAV progression as compared with the cyclosporine group (n=39) at 36 months (Δ maximal intimal thickness, 0.09±0.05 versus 0.15±0.16 mm [ P=0.03]; Δ percent atheroma volume, 5.3±2.8% versus 7.6±5.9% [ P=0.03]; and Δ total atheroma volume, 33.9±71.2 versus 54.2±96.0 mm3 [ P=0.34], respectively]. At 36 months the number of everolimus patients with rejection graded ≥2R was 15 (41%) as compared with 5 (13%) in the cyclosporine group ( P=0.01). Everolimus did not affect CAV morphology or immune marker activity during the follow-up period. Conclusions The SCHEDULE trial demonstrates that everolimus initiation and early cyclosporine elimination significantly reduces CAV progression at 12 months, and this beneficial effect is clearly sustained at 36 months. Clinical trial registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT01266148.
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Affiliation(s)
- Satish Arora
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway (S.A., A.K.A., E.G., L.G.).,Center for Heart Failure Research, University of Oslo and Faculty of Medicine, University of Oslo, Norway (S.A.)
| | - Arne K Andreassen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway (S.A., A.K.A., E.G., L.G.)
| | - Kristjan Karason
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (K.K., D.I.)
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (F.G.)
| | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Denmark (H.E., H.E.B.)
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Denmark (H.E., H.E.B.)
| | - Göran Rådegran
- The Section for Heart Failure and Valvular Disease, VO Heart and Lung Medicine, Skåne University Hospital and Department of Clinical Sciences, Lund University, Sweden (G.R.)
| | - Einar Gude
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway (S.A., A.K.A., E.G., L.G.)
| | - Dan Ioanes
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (K.K., D.I.)
| | - Dag Solbu
- Novartis Norge AS, Oslo, Norway (D.S.)
| | - Göran Dellgren
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden (G.D.)
| | - Thor Ueland
- Research Institute of Internal Medicine, Oslo University Hospital, Rikshospitalet, Norway (T.U., P.A.).,K.G. Jebsen Inflammatory Research Center, Faculty of Medicine, University of Oslo, Norway (T.U., P.A.).,K. G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø, Norway (T.U., P.A.).,Faculty of Medicine, University of Oslo, Norway (T.U., P.A., L.G.)
| | - Pål Aukrust
- Research Institute of Internal Medicine, Oslo University Hospital, Rikshospitalet, Norway (T.U., P.A.).,Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Rikshospitalet, Norway (P.A.).,K.G. Jebsen Inflammatory Research Center, Faculty of Medicine, University of Oslo, Norway (T.U., P.A.).,K. G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø, Norway (T.U., P.A.).,Faculty of Medicine, University of Oslo, Norway (T.U., P.A., L.G.)
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway (S.A., A.K.A., E.G., L.G.).,Faculty of Medicine, University of Oslo, Norway (T.U., P.A., L.G.)
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6
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Design and rationale of the HITTS randomized controlled trial: Effect of High-intensity Interval Training in de novo Heart Transplant Recipients in Scandinavia. Am Heart J 2016; 172:96-105. [PMID: 26856221 DOI: 10.1016/j.ahj.2015.10.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 10/04/2015] [Indexed: 12/11/2022]
Abstract
There is no consensus on how, when, and at what intensity exercise should be performed and organized after heart transplantation (HTx). Most rehabilitation programs are conducted in HTx centers, which might be impractical and costly. We have recently shown that high-intensity interval training (HIT) is safe, well tolerated, and efficacious in maintenance HTx recipients, but there are no studies among de novo patients, and whether HIT is feasible and superior to moderate training in HTx recipients is unclear. A total of 120 clinically stable HTx recipients older than 18 years will be recruited from 3 Scandinavian HTx centers. Participants are randomized to HIT or moderate training, shortly after surgery. All exercises are supervised in the patients' local communities. Testing at baseline and follow-up includes the following: VO2peak (primary end point), muscle strength, body composition, quality of life, myocardial performance, endothelial function, biomarkers, and progression of cardiac allograft vasculopathy. A subgroup (n = 90) will also be tested at 3-year follow-up to assess long-term effects of exercise. So far, the HIT intervention is well tolerated, without any serious adverse events. We aim to test whether decentralized HIT is feasible, safe, and superior to moderate training, and whether it will lead to significant improvement in exercise capacity and less long-term complications.
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7
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Jeewa A, Chin C, Pahl E, Atz AM, Carboni MP, Pruitt E, Naftel DC, Rodriguez R, Dipchand AI. Outcomes after percutaneous coronary artery revascularization procedures for cardiac allograft vasculopathy in pediatric heart transplant recipients: A multi-institutional study. J Heart Lung Transplant 2015; 34:1163-8. [DOI: 10.1016/j.healun.2014.11.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 10/16/2014] [Accepted: 11/04/2014] [Indexed: 11/29/2022] Open
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8
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Arora S, Andreassen AK, Andersson B, Gustafsson F, Eiskjaer H, Bøtker HE, Rådegran G, Gude E, Ioanes D, Solbu D, Sigurdardottir V, Dellgren G, Erikstad I, Solberg OG, Ueland T, Aukrust P, Gullestad L. The Effect of Everolimus Initiation and Calcineurin Inhibitor Elimination on Cardiac Allograft Vasculopathy in De Novo Recipients: One-Year Results of a Scandinavian Randomized Trial. Am J Transplant 2015; 15:1967-75. [PMID: 25783974 DOI: 10.1111/ajt.13214] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 12/23/2014] [Accepted: 12/31/2014] [Indexed: 01/25/2023]
Abstract
Early initiation of everolimus with calcineurin inhibitor therapy has been shown to reduce the progression of cardiac allograft vasculopathy (CAV) in de novo heart transplant recipients. The effect of de novo everolimus therapy and early total elimination of calcineurin inhibitor therapy has, however, not been investigated and is relevant given the morbidity and lack of efficacy of current protocols in preventing CAV. This 12-month multicenter Scandinavian trial randomized 115 de novo heart transplant recipients to everolimus with complete calcineurin inhibitor elimination 7-11 weeks after HTx or standard cyclosporine immunosuppression. Ninety-five (83%) patients had matched intravascular ultrasound examinations at baseline and 12 months. Mean (± SD) recipient age was 49.9 ± 13.1 years. The everolimus group (n = 47) demonstrated significantly reduced CAV progression as compared to the calcineurin inhibitor group (n = 48) (ΔMaximal Intimal Thickness 0.03 ± 0.06 and 0.08 ± 0.12 mm, ΔPercent Atheroma Volume 1.3 ± 2.3 and 4.2 ± 5.0%, ΔTotal Atheroma Volume 1.1 ± 19.2 mm(3) and 13.8 ± 28.0 mm(3) [all p-values ≤ 0.01]). Everolimus patients also had a significantly greater decline in levels of soluble tumor necrosis factor receptor-1 as compared to the calcineurin inhibitor group (p = 0.02). These preliminary results suggest that an everolimus-based CNI-free can potentially be considered in suitable de novo HTx recipients.
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Affiliation(s)
- S Arora
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - A K Andreassen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - B Andersson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - F Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - H Eiskjaer
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - H E Bøtker
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - G Rådegran
- The Clinic for Heart Failure and Valvular Disease, Skåne University Hospital and Lund University, Lund, Sweden
| | - E Gude
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - D Ioanes
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - D Solbu
- Novartis Norge AS, Oslo, Norway
| | - V Sigurdardottir
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - G Dellgren
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - I Erikstad
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - O G Solberg
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - T Ueland
- Research Institute for Internal Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,K.G. Jebsen Inflammatory Research Center, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - P Aukrust
- Research Institute for Internal Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,K.G. Jebsen Inflammatory Research Center, Faculty of Medicine, University of Oslo, Oslo, Norway.,Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - L Gullestad
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway.,K.G. Jebsen Cardiac Research Center and Center for Heart Failure Research, Faculty of Medicine, University of Oslo, Oslo, Norway
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9
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Cardiac allograft vasculopathy: a donor or recipient induced pathology? J Cardiovasc Transl Res 2015; 8:106-16. [PMID: 25652948 PMCID: PMC4382530 DOI: 10.1007/s12265-015-9612-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 01/14/2015] [Indexed: 01/16/2023]
Abstract
Cardiac allograft vasculopathy (CAV) is one of the main causes of late-stage heart failure after heart transplantation. CAV is characterized by concentric luminal narrowing of the coronary arteries, but the exact pathogenesis of CAV is still not unraveled. Many researchers show evidence of an allogeneic immune response of the recipient, whereas others show contrasting results in which donor-derived cells induce an immune response against the graft. In addition, fibrosis of the neo-intima can be induced by recipient-derived circulating cells or donor-derived cells. In this review, both donor and recipient sides of the story are described to obtain better insight in the pathogenesis of CAV. Dual outcomes were found regarding the contribution of donor and recipient cells in the initiation of the immune response and the development of fibrosis during CAV. Future research could focus more on the potential synergistic interaction of donor and recipient cells leading to CAV.
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10
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Dedieu N, Greil G, Wong J, Fenton M, Burch M, Hussain T. Diagnosis and management of coronary allograft vasculopathy in children and adolescents. World J Transplant 2014; 4:276-293. [PMID: 25540736 PMCID: PMC4274597 DOI: 10.5500/wjt.v4.i4.276] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 08/12/2014] [Accepted: 09/17/2014] [Indexed: 02/05/2023] Open
Abstract
Coronary allograft vasculopathy remains one of the leading causes of death beyond the first year post transplant. As a result of denervation following transplantation, patients lack ischaemic symptoms and presentation is often late when the graft is already compromised. Current diagnostic tools are rather invasive, or in case of angiography, significantly lack sensitivity. Therefore a non-invasive tool that could allow early diagnosis would be invaluable.This paper review the disease form its different diagnosis techniques,including new and less invasive diagnostic tools to its pharmacological management and possible treatments.
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11
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Chou CL, Chou CY, Huang YY, Wu MS, Hsu CC, Chou YC. Prescription trends of immunosuppressive drugs in post-heart transplant recipients in Taiwan, 2000-2009. Pharmacoepidemiol Drug Saf 2014; 23:1312-9. [PMID: 25335855 PMCID: PMC4286022 DOI: 10.1002/pds.3722] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 07/31/2014] [Accepted: 09/10/2014] [Indexed: 02/01/2023]
Abstract
PURPOSE Significantly increasing heart transplantations have been performed in Taiwan in the past decades, but the trends of maintenance immunosuppression for heart transplant recipients have not been well known. In this study, we aimed to explore the trends of maintenance immunosuppressive therapy and common complications for heart transplant recipients. METHODS We retrospectively analyzed ambulatory prescriptions in 488 heart transplant recipients for the period 2000-2009. Patient complications after heart transplantation were also identified. RESULTS The annual number of new heart transplant recipients ranged from 18 to 68. The 5-year survival rate was 77.9%. The total number of regimens was 10 in 2000, and increased to 28 in 2009. Most prescriptions were immunosuppressive combinations (95.5%-89.5%). The majority of immunosuppressive regimens were a triple regimen: cyclosporine, mycophenolic acid and corticosteroid in 2009. Cyclosporine was a predominant calcineurin inhibitor with a decreasing trend from 73.9% to 59.1%, whereas the use of tacrolimus significantly increased from 11.9% to 38.4%. Mycophenolic acid was the most frequently used antimetabolite (60.1%-80.3%), while the use of azathioprine was reduced (21.6%-2.3%). From 2008, the launch of everolimus initiated a new era in the utilization of mammalian target of rapamycin inhibitors for maintenance immunosuppression. CONCLUSIONS Cyclosporine remained the most frequently used calcineurin inhibitors, and tacrolimus increased gradually. Mycophenolic acid was the most popular antimetabolite rather than azathioprine. The rapidly increased everolimus combined regimen may change the patterns of maintenance immunosuppression. The increasing number of combination therapies indicates an active role of everolimus and a tendency of complex tailored individual therapies.
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Affiliation(s)
- Chia-Lin Chou
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
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12
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13
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Baraldo M, Gregoraci G, Livi U. Steroid-free and steroid withdrawal protocols in heart transplantation: the review of literature. Transpl Int 2014; 27:515-29. [PMID: 24617420 PMCID: PMC4229061 DOI: 10.1111/tri.12309] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2012] [Revised: 01/11/2013] [Accepted: 03/06/2014] [Indexed: 01/05/2023]
Abstract
Corticosteroids (CSs) are still the mainstay of induction, rescue, and maintenance in heart transplantation (HTx). However, their use is associated with significant and well-documented side effects usually related to the dose administered and the duration of therapy. Moreover, CSs interfere with the recipient's quality of life and with the active process of graft tolerance. Physicians have been exploring ways to avoid or reduce CSs in association with other immunosuppressive drugs, minimizing side effects and costs. The regimens are classified as steroid-free or steroid withdrawal protocols. The studies analyzed in this review come to similar conclusions as benefits and adverse consequences: steroid-free protocols should be advisable and mandatory in pediatric patients, insulin-dependent diabetes mellitus (IDDM), presence of infection, familial metabolic disorders/obesity, severe osteoporosis, and in the elderly. On the other hand, steroid withdrawal can be successfully achieved in 50-80%, with late better than early withdrawal, no increase in rejection-related mortality, no adverse impact on survival, and probably a better quality of live. Safety and efficacy can certainly be improved by an individualized approach to the transplant recipient.
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Affiliation(s)
- Massimo Baraldo
- Department of Experimental and Clinical Medicine, Medical School, University of Udine, Udine, Italy; SOC Institute of Clinical Pharmacology, University-Hospital Santa Maria della Misericordia, Udine, Italy
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14
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Som R, Morris PJ, Knight SR. Graft Vessel Disease Following Heart Transplantation: A Systematic Review of the Role of Statin Therapy. World J Surg 2014; 38:2324-34. [DOI: 10.1007/s00268-014-2543-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Nytrøen K, Gullestad L. Exercise after heart transplantation: An overview. World J Transplant 2013; 3:78-90. [PMID: 24392312 PMCID: PMC3879527 DOI: 10.5500/wjt.v3.i4.78] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 07/15/2013] [Accepted: 07/25/2013] [Indexed: 02/05/2023] Open
Abstract
While life expectancy is greatly improved after a heart transplant, survival is still limited, and compared to the general population, the exercise capacity and health-related quality of life of heart transplant recipients are reduced. Increased exercise capacity is associated with a better prognosis. However, although several studies have documented positive effects of exercise after heart transplantation (HTx), little is known about the type, frequency and intensity of exercise that provides the greatest health benefits. Moreover, the long-term effects of exercise on co-morbidities and survival are also unclear. Exercise restrictions apply to patients with a denervated heart, and for decades, it was believed that the transplanted heart remained denervated. This has since been largely disproved, but despite the new knowledge, the exercise restrictions have largely remained, and up-to-date guidelines on exercise prescription after HTx do not exist. High-intensity, interval based aerobic exercise has repeatedly been documented to have superior positive effects and health benefits compared to moderate exercise. This applies to both healthy subjects as well as in several patient groups, such as patients with metabolic syndrome, coronary artery disease or heart failure. However, whether the effects of this type of exercise are also applicable to heart transplant populations has not yet been fully established. The purpose of this article is to give an overview of the current knowledge about the exercise capacity and effect of exercise among heart transplant recipients and to discuss future exercise strategies.
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Nytrøen K, Rustad LA, Erikstad I, Aukrust P, Ueland T, Lekva T, Gude E, Wilhelmsen N, Hervold A, Aakhus S, Gullestad L, Arora S. Effect of high-intensity interval training on progression of cardiac allograft vasculopathy. J Heart Lung Transplant 2013; 32:1073-80. [PMID: 23906899 DOI: 10.1016/j.healun.2013.06.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 06/25/2013] [Accepted: 06/25/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is a progressive form of atherosclerosis occurring in heart transplant (HTx) recipients, leading to increased morbidity and mortality. Given the atheroprotective effect of exercise on traditional atherosclerosis, we hypothesized that high-intensity interval training (HIIT) would reduce the progression of CAV among HTx recipients. METHODS Forty-three cardiac allograft recipients (mean ± SD age 51 ± 16 years; 67% men; time post-HTx 4.0 ± 2.2 years), all clinically stable and >18 years old, were randomized to either a HIIT group or control group (standard care) for 1 year. The effect of training on CAV progression was assessed by intravascular ultrasound (IVUS). RESULTS IVUS analysis revealed a significantly smaller mean increase [95% CI] in atheroma volume (PAV) of 0.9% [95% CI -;0.3% to 1.9%] in the HIIT group as compared with the control group, 2.5% [1.6% to 3.5%] (p = 0.021). Similarly, the mean increase in total atheroma volume (TAV) was 0.3 [0.0 to 0.6] mm(3)/mm in the HIT group vs 1.1 [0.6 to 1.7] mm(3)/mm in the control group (p = 0.020), and mean increase in maximal intimal thickness (MIT) was 0.02-0.01 to 0.04] mm in the HIIT group vs 0.05 [0.03 to 0.08] mm in the control group (p = 0.054). Qualitative plaque progression (virtual histology parameters) and inflammatory activity (biomarkers) were similar between the 2 groups during the study period. CONCLUSIONS HIIT among maintenance HTx recipients resulted in a significantly impaired rate of CAV progression. Future larger studies should address whether exercise rehabilitation strategies should be included in CAV management protocols.
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Affiliation(s)
- Kari Nytrøen
- Department of Cardiology, Oslo University Hospital HF Rikshospitalet, Oslo.
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Watanabe T. The role of everolimus in treatment of cardiac allograft vasculopathy. J Cardiol Cases 2013; 7:e184-e185. [PMID: 30533159 PMCID: PMC6275357 DOI: 10.1016/j.jccase.2013.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Indexed: 11/19/2022] Open
Affiliation(s)
- Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata 990-9585, Japan
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Lavine KJ, Sintek M, Novak E, Ewald G, Geltman E, Joseph S, Pfeifer J, Mann DL. Coronary collaterals predict improved survival and allograft function in patients with coronary allograft vasculopathy. Circ Heart Fail 2013; 6:773-84. [PMID: 23709657 DOI: 10.1161/circheartfailure.113.000277] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite improvements in the care of patients who have received cardiac transplants, coronary allograft vasculopathy (CAV) remains the most prevalent cause of late allograft failure and cardiac mortality. Few proven therapies are available for this important disease. The presence of coronary collaterals imparts a favorable prognosis in patients with native ischemic heart disease; however, the impact of collaterals in CAV is unknown. METHODS AND RESULTS To determine whether the development of coronary collaterals is associated with improved outcomes in patients with CAV, we performed a retrospective analysis of patients followed in the heart transplant program at Barnes Jewish Hospital from 1994 to 2008. The primary end points included all cause mortality and the composite of all cause mortality, retransplantation, and inotrope dependence. We screened 485 patients and identified 59 (12%) subjects with moderate-to-severe CAV. Angiographically visible coronary collaterals were present in 34 (57%) subjects. Kaplan-Meier and Cox multivariable analyses revealed that patients with collaterals had reduced incidence of all cause mortality (hazard ratio, 0.20; P<0.001) and the composite end point (hazard ratio, 0.17; P<0.001). In addition, patients with collaterals had less severe heart failure symptoms as measured by New York Heart Association class. Immunostaining of biopsy specimens revealed that among patients with CAV, the presence of coronary collaterals correlated with increased microvascular density, reduced fibrosis, and decreased left ventricular end-diastolic pressure. CONCLUSIONS Together, these data demonstrate that the presence of coronary collaterals predicts a favorable prognosis in patients with CAV and suggests that interventions aimed at promoting collateral and microvascular growth may serve as effective therapies for this disease.
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Affiliation(s)
- Kory J Lavine
- Division of Cardiology, Center for Cardiovascular Research, Washington University School of Medicine, St Louis, MO 63110, USA.
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19
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Effect of Everolimus Introduction on Cardiac Allograft Vasculopathy—Results of a Randomized, Multicenter Trial. Transplantation 2011; 92:235-43. [DOI: 10.1097/tp.0b013e31822057f1] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Booth AJ, Bishop DK. TGF-beta, IL-6, IL-17 and CTGF direct multiple pathologies of chronic cardiac allograft rejection. Immunotherapy 2010; 2:511-20. [PMID: 20636005 DOI: 10.2217/imt.10.33] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Cardiac transplantation is an effective treatment for heart failure refractive to therapy. Although immunosuppressive therapeutics have increased first year survival rates, chronic rejection remains a significant barrier to long-term graft survival. Chronic rejection manifests as patchy interstitial fibrosis, vascular occlusion and progressive loss of graft function. Recent evidence from experimental and patient studies suggests that the development of cardiomyocyte hypertrophy is another hallmark of chronic cardiac allograft rejection. This pathologic hypertrophy is tightly linked to the immune cytokine IL-6, which promotes facets of chronic rejection in concert with TGF-beta and IL-17. These factors potentiate downstream mediators, such as CTGF, which promote the fibrosis associated with the disease. In this article, we summarize contemporary findings that have revealed several elements involved in the induction and progression of chronic rejection of cardiac allografts. Further efforts to elucidate the interplay between these factors may direct the development of targeted therapies for this disease.
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Affiliation(s)
- Adam J Booth
- Division of Pulmonary & Critical Care, Department of Internal Medicine, University of Michigan Medical Center, 6240 MSRBIII/0624, 1150 W Medical Center Drive, Ann Arbor, MI 48109, USA.
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Caliskan K, Balk AHHM, Wykrzykowska JJ, van Geuns RJ, Serruys PW. How should I treat an unusual referral for heart transplantation? EUROINTERVENTION 2010; 5:861-5. [PMID: 20142204 DOI: 10.4244/eijv5i7a144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND A 55 years old man was referred for cardiac transplantation because of intractable angina and fatigue. INVESTIGATION Physical examination, laboratory test, echocardiography, exercise ECG, MRI and coronary arteriography. DIAGNOSIS Multiple coronary artery fistulae. MANAGEMENT Beta-blockers, angiotensin-converting enzyme inhibitor ICD.
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22
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King CL, Devitt JJ, Lee TDG, Hancock Friesen CL. Neutrophil mediated smooth muscle cell loss precedes allograft vasculopathy. J Cardiothorac Surg 2010; 5:52. [PMID: 20569484 PMCID: PMC2909951 DOI: 10.1186/1749-8090-5-52] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Accepted: 06/22/2010] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (AV) is a pathological process of vascular remodeling leading to late graft loss following cardiac transplantation. While there is consensus that AV is alloimmune mediated, and evidence that the most important alloimmune target is medial smooth muscle cells (SMC), the role of the innate immune response in the initiation of this disease is still being elucidated. As ischemia reperfusion (IR) injury plays a pivotal role in the initiation of AV, we hypothesize that IR enhances the early innate response to cardiac allografts. METHODS Aortic transplants were performed between fully disparate mouse strains (C3H/HeJ and C57BL/6), in the presence of therapeutic levels of Cyclosporine A, as a model for cardiac AV. Neutrophils were depleted from some recipients using anti-PMN serum. Grafts were harvested at 1,2,3,5d and 1,2wk post-transplant. Ultrastructural integrity was examined by transmission electron microscopy. SMC and neutrophils were quantified from histological sections in a blinded manner. RESULTS Grafts exposed to cold ischemia, but not transplanted, showed no medial SMC loss and normal ultrastructural integrity. In comparison, allografts harvested 1d post-transplant exhibited > 90% loss of SMC (p < 0.0001). SMC partially recovered by 5d but a second loss of SMC was observed at 1wk. SMC loss at 1d and 1wk post-transplant correlated with neutrophil influx. SMC loss was significantly reduced in neutrophil depleted recipients (p < 0.01). CONCLUSIONS These novel data show that there is extensive damage to medial SMC at 1d post-transplant. By depleting neutrophils from recipients it was demonstrated that a portion of the SMC loss was mediated by neutrophils. These results provide evidence that IR activation of early innate events contributes to the etiology of AV.
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Affiliation(s)
- Chelsey L King
- Department of Pathology, 5850 College St, Dalhousie University, Halifax, NS, Canada
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23
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Suzuki JI, Isobe M, Morishita R, Nagai R. Characteristics of Chronic Rejection in Heart Transplantation: Important Elements of Pathogenesis and Future Treatments. Circ J 2010; 74:233-9. [DOI: 10.1253/circj.cj-09-0809] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jun-ichi Suzuki
- Department of Advanced Clinical Science and Therapeutics, University of Tokyo
| | - Mitsuaki Isobe
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | | | - Ryozo Nagai
- Department of Cardiovascular Medicine, University of Tokyo
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25
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Delgado JF, Manito N, Segovia J, Almenar L, Arizón JM, Campreciós M, Crespo-Leiro MG, Díaz B, González-Vílchez F, Mirabet S, Palomo J, Roig E, de la Torre JM. The use of proliferation signal inhibitors in the prevention and treatment of allograft vasculopathy in heart transplantation. Transplant Rev (Orlando) 2009; 23:69-79. [PMID: 19298938 DOI: 10.1016/j.trre.2009.01.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Cardiac allograft vasculopathy (CAV) currently represents one of the most important causes of long-term morbidity and mortality in the heart transplant population. In well-designed studies with de novo patients, the use of proliferation signal inhibitors (PSIs; everolimus and sirolimus) has been shown to significantly prevent the intimal growth of graft coronary arteries in comparison to other immunosuppressive regimens, reducing the incidence of vasculopathy at 12 and 24 months. In addition, conversion to PSIs in maintenance patients with established CAV has also shown promising results in the reduction of the progression of the disease and its clinical consequences. For these reasons the interest shown by various transplantation units in the potential role of PSIs in this field is growing. The aim of the present article is to review the information obtained to date on the use of PSIs in heart transplant recipients, both in the prevention and the treatment of CAV. The principal published recommendations on the introduction and appropriate management of these drugs in clinical practice are also collected, as well as certain recommendations given by the authors based on their experience.
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Affiliation(s)
- Juan F Delgado
- Unidad de Insuficiencia Cardiaca y Trasplante, Servicio de Cardiología, Hospital 12 de Octubre, 28041 Madrid, Spain.
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Abstract
Cardiac allograft vasculopathy (CAV) remains a life-threatening complication after heart transplantation (HT). Recipients with severe intimal thickening are 10-fold more likely to suffer cardiac events than those without severe hyperplasia. From July 1987 to July 2007, we performed 323 HTs with 5-year actuarial freedom from CAV of 69%, similar to the data reported by the International Society for Heart and Lung Transplantation, namely, 68% at 5 years. Therefore, CAV is not uncommon in Asia. The pathogenesis of CAV is initial endothelial injury followed by intimal hyperplasia and proliferation of vascular smooth muscle cells. It may be caused by both immunological events (involving T or B cells in response to donor major histocompatibility antigens, or natural killer [NK] cell-triggered recruitment of T cells not responsive to donor alloantigen) and nonimmunologic factors, such as older age, ischemia-reperfusion injury, viral infection (particularly cytomegalovirus [CMV] infection), immunosuppressive drugs, and classic risk factors, such as hyperlipidemia, insulin resistance, and hypertension. The therapy for CAV has been disappointing, despite prescriptions of statin lipid-lowering agents, calcium-channel blockers, angiotensin-converting enzyme inhibitors, and antiproliferative drugs. Patients with CAV are often not amenable to successful revascularization (medical or surgical) because of the diffuse obliterative process. Prophylaxis of CAV starts with modification of risk factors: hypertension, hyperlipemia, hyperglycemia, obesity, and smoking, as well as promotion of exercise programs. The HMG-CoA reductase inhibitors and antiproliferative drugs may slow the progression of CAV by various immunologic and nonimmunologic effects. Prevention of CMV infection reduces CAV. Mycophenolate mofetil and signal transduction inhibitors, such as everolimus, reduce intimal thickening and CAV.
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Affiliation(s)
- S-S Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
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Abstract
Cardiac allograft vasculopathy (CAV) continues to limit the long-term success of cardiac transplantation. Recent insights have underscored the fact that innate and adaptive immune responses are involved in the pathogenesis of CAV. Vascular lesions are the result of cumulative endothelial injuries induced both by alloimmune responses and by nonspecific insults (including ischemia-reperfusion injury, viral infections, and metabolic disorders) in the context of impaired repair mechanisms. Intravascular ultrasound is the most sensitive method for detection of CAV, and progressive intimal thickening in the first posttransplant year identifies patients at high risk for future cardiovascular events. Encouraging results with regard to the detection of CAV by noninvasive methods should be an incentive to apply routine noninvasive imaging during mid- to long-term follow-up. Improved immunosuppressive drugs, including mycophenolate mofetil and proliferation signal inhibitors, as well as statins (in part via immunomodulation), have beneficial effects on CAV progression, although there is still a need to confirm the impact of vasodilators in improving outcome after heart transplantation. Coronary revascularization for CAV is only palliative, with no long-term survival benefit. Three main strategies for CAV prevention are currently under investigation: inhibition of growth factors and cytokines, cell therapy, and tolerance induction. However, because individual responses to an allograft change over time, assays to monitor the recipient's immune response and individualized methods for therapeutic immune modulation are clearly needed.
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Affiliation(s)
- Daniel Schmauss
- Medizinische Klinik und Poliklinik I, University Hospital Munich-Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany
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Abstract
To discuss the indications for and outcomes of cardiac retransplantation in childhood. The major challenge of pediatric heart transplantation is graft failure. The major causes of graft failure include coronary allograft vasculopathy and chronic rejection. Retransplantation may be considered in children or young adults who develop graft failure following pediatric heart transplantation. Retransplantation now accounts for 7% of all pediatric transplants. Recent studies have demonstrated that cardiac retransplantation has a poorer outcome than primary heart transplantation. However, the interval from primary transplant to retransplantation appears to impact significantly the success of retransplantation. When children undergo retransplantation for early graft failure, the survival is quite poor and the appropriateness of this strategy is questionable. However, children who undergo retransplantation many years after primary transplantation have outcomes that are similar to primary transplantation. The decision to pursue retransplantation depends on the severity of graft failure and recent data suggest that identification of mild graft dysfunction or coronary allograft vasculopathy does not imply impending graft failure. Novel therapies to extend the life of the primary graft and to stratify those at risk of severe graft dysfunction will improve the allocation of scarce organs for pediatric patients who might be candidates for cardiac retransplantation. Retransplantation can extend the lives of children who develop graft failure after primary transplantation. However, not all patients who develop graft dysfunction should necessarily be listed for retransplantation.
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Affiliation(s)
- William T Mahle
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA 30322-1062, USA.
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Proliferation Signal Inhibitors in Transplantation: Questions at the Cutting Edge of Everolimus Therapy. Transplant Proc 2007; 39:2937-50. [DOI: 10.1016/j.transproceed.2007.09.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2007] [Accepted: 09/02/2007] [Indexed: 12/23/2022]
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