Does the induction immunotherapy (basiliximab) influence the early acute cellular rejection index after orthotopic heart transplantation?- Preliminary assessment report

The study aimed to determine the influence of induction therapy on the acute cellular rejection (ACR) index in adult heart transplant recipients during the one-year observation. The study population consisted of 256 consecutive adult patients (pts), aged 51.5 (±11.9) years, 199 (77%) men treated with orthotopic heart transplantation (OHT) in the period between 2015 and 2020 in a single high-volume heart transplant center. The endomyocardial biopsies (EMBs) were performed according to the protocol consisting of 7 protocolary EMBs for up to 3 months and 10 EMBs for up to one year after OHT. The rejection index (ACRI) was calculated as the number of scheduled EMBs with the ACR ≥ 2 divided by the total number of protocolary EMBs. The study population was divided into two groups according to the application of basiliximab. The total number of pts. who received basiliximab was 10 (3.9%). The main indications for the usage of the induction therapy were heart retransplantation, mechanical circulatory support (MCS), severe renal insufficiency (eGFR <30 mL/min/1.73 m2), and a panel of reactive antibody (PRA) > 10%. In the group with induction, the mean age was 49 (±14) years; 3 (30%) patients had the MCS prior to OHT, and 3 (30%) patients had heart retransplantation. Four (40%) patients had diabetes mellitus, and 4 (40%) patients had severe renal insufficiency. As maintenance therapy during the observation period, tacrolimus was given to 10 (100%) patients, everolimus to 2 (20%) patients, and MPA to 9 (90%) patients. In the group with no induction, the mean age was 51.8 (±12) years, MCS was used in 56 (23%) patients, 2 (0.8%) patients were retransplanted; 10 (4%) patients had eGFR <30 mL/min/1.73 m2 and 58 (24%) patients had diabetes. Tacrolimus was administered to 243 (99%) patients, cyclosporine to 3 (1%), everolimus to 40 (16%), and mycophenolate to 245 (99.6%) heart recipients. The median one-year ACRI was 0.0, IQR:0.0-0.08 in the group with induction vs. 0.077, IQR: 0.0-0.154 with no induction; p = 0.11. ACRI up to three months was significantly higher in the entire cohort in comparison to up to one year (P < 0.01). The multivariate analysis showed that only everolimus implementation and younger age at the time of transplant influenced patients' mortality rate (P < 0.01). Significant graft rejections (≥ 2R ISHLT) are most common in the first three months after OHT. Patients who are initially at high risk of significant cellular rejection may benefit from induction therapy.

Gut Microbiome in Patients after Heart Transplantation-Current State of Knowledge

The human gut microbiota include over 10 trillion microorganisms, such as bacteria, fungi, viruses, archaea, and protozoa. Many reports indicate the strong correlation between dysbiosis and the severity of cardiovascular diseases. Microbiota seem to interact with the host's alloimmunity and may have an immunomodulatory role in graft rejection processes. In our study, we present the current state of the knowledge of microbiota in heart transplant recipients. We present up-to-date microbiota diagnostic methods, interactions between microbiota and immunosuppressive drugs, the immunomodulatory effects of dysbiosis, and the available strategies (experimental and clinical strategies) to modulate host microbiota.

The implantation of AV leadless pacemaker - a case report

In early 2020 Food and Drug Administration (FDA) approved Micra AV - a new type of leadless pacemaker with atrioventricular synchrony, to treat patients with atrio-ventricular (AV) blocks. We describe one of the first in Poland case of a patient who was implanted with Micra AV pacemaker.

CASE REPORT

A 38-year-old female patient was admitted to the clinic due to the 29-seconds event of a complete AV block without an escape rhythm and was implanted with a dual chamber pacemaker without any complications. After several months she was admitted again with suspicion of ventricular perforation by the pacemaker electrode and underwent a replacement procedure of both pacemaker's leads. Nevertheless, one week later the patient developed a fever with significantly elevated inflammatory markers. The blood cultures were negative but in the transesophageal echocardiography features of cardiac device-related infective endocarditis were observed. Empirical antibiotic therapy was administered, and the device was removed. The Heart Team qualified the patient for the implantation of a MicraTM AV leadless pacemaker. The procedure was performed without any complications and the device was implanted to the right ventricle. All parameters were correct, and the patient was discharged.

CONCLUSIONS

Micra AV may be a feasible and safe option for young patients with paroxysmal AV block after device-related complications.

Quality of life in patients with a subcutaneous vs. transvenous implantable cardioverter-defibrillator

BACKGROUND

The implantable cardioverter-defibrillator (ICD) and subcutaneous ICD (S-ICD) are well-accepted life-saving devices for treating potentially lethal ventricular arrhythmia, but little is known about quality of life (QoL) in patients with S-ICD and ICD.

AIMS

Our study aimed to compare QoL in patients with S-ICD and ICD.

METHODS

All consecutive patients who had S-ICD implanted between October 2015 and September 2021 were included in the study. A cohort of transvenous ICD (TV-ICD) patients was matched to S-ICD subjects by sex, age, indications for the device, and type of prevention. All patients were requested to fulfill two standardized questionnaires to assess QoL: 36-Item Short Form Health Survey (SF-36) and Minnesota Living with Heart Failure Questionnaire (MLHFQ) 6 months after device implantation.

RESULTS

Patients with S-ICD (n = 49) and TV-ICD (n = 49) did not differ regarding baseline characteristics. There were no statistically significant differences between S-ICD and TV-ICD subgroup, both for mental and physical QoL assessed in SF-36 and MLHFQ (all P = NS). The median MLHFQ total score was 24 (9-41) for S-ICD and 28 (14-43) for TV-ICD (P = 0.83). The median total score for the SF-36 questionnaire was 62.5 (29-86) vs. 59 (38-77) for S-ICD and TV-ICD, respectively (P = 0.78).

CONCLUSIONS

Quality of life after device implantation does not differ significantly between the groups of patients with subcutaneous and conventional implantable cardioverter-defibrillator.

Patient-Related Preoperative Clinical Factors Influencing 1-Year Survival After Orthotopic Heart Transplantation – A Single Center Polish Experience

Background

End-stage heart failure is a growing problem in Poland. Orthotopic heart transplantation remains the best treatment option. Although increasing, the number of heart transplants is disproportionately low compared with patient need. Therefore, it is crucial to identify factors contributing to improvement of heart transplantation outcomes. To find factors providing best survival and optimal recipient selection, we analyzed pretransplant patient-related clinical factors.

Material/Methods

Between May 2015 and May 2020, we performed 258 cardiac transplants at our institution. We reviewed possible patient-related clinical factors affecting the 1-year survival of our patients and analyzed factors related to survival. Mean age at transplant was 53.5 (±11.8) years; 22.9% of patients were women. Preoperative factors were analyzed using univariable and multivariable analyses.

Results

In this cohort, 31.8% were diabetic, 43% had ischemic etiology of heart failure, and 15.3% had reversible pulmonary hypertension. Mechanical circulatory support was used in 22%. During 1-year observation, 64 (24.8%) patients died. Univariable analysis showed ischemic etiology (hazard ratio [HR]=2.05, CI=1.227–3.429; P=0.01) and left ventricular assist device were associated with 1-year risk of death (HR=1.953, CI=1.090–3.499; P=0.02). Urgent listing trended toward worsened prognosis (HR=1.509, CI=0.95–2.397; P=0.08). Multivariable analysis showed ischemic etiology (HR=1.81, CI=1.075–3.059; P=0.03), total mechanical circulatory support (HR=1.93, CI=1.080–3.437; P=0.03), decreased eGFR (HR=0.987, CI=0.975–0.998; P=0.03), and protein level (HR=0.97, CI=0.951–0.998; P=0.04) were independently associated with worse 1-year survival after transplantation.

Conclusions

Ischemic etiology and mechanical circulatory support were the most important preoperative factors. Malnutrition and renal failure were additional risk factors. Age alone did not influence 1-year survival.

Heart Retransplantation From an Hepatitis B Core Antibody (Anti-HBcore)-Positive Donor: A Case Report

Heart transplantation is performed in patients with end-stage heart failure. The number of suitable donors for patients on the urgent heart transplantation waiting list is still low, and effort has been made to increase the number of suitable donors, including extended-criteria donors. We present a case report of heart retransplantation because of graft failure from an hepatitis B core antibody (anti-HBcore-positive, HBcAb [+]) and HBs antigen-negative (HBsAg [-]) donor to a seronegative recipient. We show that the procedure, with the use of antiviral prophylaxis, is a safe option for the recipient. Based on anatomopathologic and histopathologic examination of the explanted graft, we also suggest that acute cellular rejection in the transplanted heart may exist despite negative findings in right-sided endomyocardial biopsy.

Experimental and computational studies on the femoral fracture risk for advanced core decompression

BACKGROUND

Two questions are often addressed by orthopedists relating to core decompression procedure: 1) Is the core decompression procedure associated with a considerable lack of structural support of the bone? and 2) Is there an optimal region for the surgical entrance point for which the fracture risk would be lowest? As bioresorbable bone substitutes become more and more common and core decompression has been described in combination with them, the current study takes this into account.

METHODS

Finite element model of a femur treated by core decompression with bone substitute was simulated and analyzed. In-vitro compression testing of femora was used to confirm finite element results.

FINDINGS

The results showed that for core decompression with standard drilling in combination with artificial bone substitute refilling, daily activities (normal walking and walking downstairs) are not risky for femoral fracture. The femoral fracture risk increased successively when the entrance point is located further distal. The critical value of the deviation of the entrance point to a more distal part is about 20mm.

INTERPRETATION

The study findings demonstrate that optimal entrance point should locate on the proximal subtrochanteric region in order to reduce the subtrochanteric fracture risk. Furthermore the consistent results of finite element and in-vitro testing imply that the simulations are sufficient.

Arthroscopic synovectomy and radiosynoviorthesis: a treatment option for recurrent arthritis symptoms in patients with pachydermoperiostosis

Pachydermoperiostosis as the primary form of hypertrophic osteoarthropathy is a rare hereditary disorder with a number of characteristic findings, e.g. periosteal hypertrophy, digital clubbing and pachydermia. Further typical symptoms include arthritic manifestations in all major joints. Literature review showed that therapeutical approaches usually focus on medical therapy alleviating chronic polyarthritis by controlling inflammation. In the case presented in this report anti-inflammatory therapy appeared to have been insufficient since knee arthritis persisted. Arthroscopic synovectomy and radiosynoviorthesis were performed consecutively. Postoperative and follow-up examinations indicate that this combined therapy reduces pain, increases range of motion and improves overall mobility, and is thus of lasting benefit to the patient.