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Alam A, van Zyl JS, Patel R, Jamil AK, Felius J, Carey SA, Gottlieb RL, Guerrero-Miranda CY, Kale P, Hall SA, Sam T. Three-year outcomes of de novo tacrolimus extended-release tablets (LCPT) compared to twice-daily tacrolimus in adult heart transplantation. Transpl Immunol 2024; 83:102009. [PMID: 38325525 DOI: 10.1016/j.trim.2024.102009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/31/2024] [Accepted: 02/03/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND Extended-release tacrolimus for prophylaxis of allograft rejection in heart transplant (HT) recipients is currently not FDA-approved. One such extended-release formulation of tacrolimus known as LCPT allows once-daily dosing and improves bioavailability compared to immediate-release (IR-) tacrolimus. We compared long-term efficacy and safety of LCPT to IR-tacrolimus applied de novo in adult OHT recipients. METHODS 25 prospective recipients on LCPT at our center from 2017 to 2019 were matched 1:2 with historical control recipients treated with IR-tacrolimus based on age, gender, and baseline creatinine. The primary composite outcome of death, acute cellular rejection, and/or new graft dysfunction within 3 years following transplant was compared between groups using non-inferiority analysis. RESULTS LCPT demonstrated non-inferiority to IR-tacrolimus, with a primary outcome risk reduction of 16% (90%CI, -37%, -1%, non-inferiority p = 0.002) up to 3 years following heart transplant. Up to 3-years post-transplant, 14 patients remained on once-daily LCPT and 10 patients were switched to IR-tacrolimus due to lack of insurance coverage. There were no significant differences in the rate of chronic kidney disease requiring dialysis, cytomegalovirus requiring treatment, cardiac allograft vasculopathy, and malignancy within 3 years following transplant. CONCLUSION LCPT is non-inferior in efficacy to IR-tacrolimus in heart transplantation with a similar safety profile. Narrowly-constrained FDA labels specific to kidney transplant remain a barrier to consistent access to many immunosuppressant medications for recipients of non-kidney solid organs. We recommend the FDA consider developing facile pathways for expanding the approved label of extended-release tacrolimus formulations to heart transplant recipients.
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Affiliation(s)
- Amit Alam
- Division of Cardiology, New York University, New York City, NY, USA
| | - Johanna S van Zyl
- Texas A&M Health Science Center, Dallas, TX, USA; Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, TX, USA
| | - Raksha Patel
- Department of Pharmacy, Baylor University Medical Center, Dallas, TX, USA
| | - Aayla K Jamil
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, TX, USA
| | - Joost Felius
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, TX, USA
| | - Sandra A Carey
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX, USA
| | - Robert L Gottlieb
- Texas A&M Health Science Center, Dallas, TX, USA; Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, TX, USA; Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX, USA; Baylor Scott & White Heart and Vascular Hospital, Dallas, TX, USA
| | - Cesar Y Guerrero-Miranda
- Texas A&M Health Science Center, Dallas, TX, USA; Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX, USA; Baylor Scott & White Heart and Vascular Hospital, Dallas, TX, USA
| | - Parag Kale
- Texas A&M Health Science Center, Dallas, TX, USA; Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX, USA; Baylor Scott & White Heart and Vascular Hospital, Dallas, TX, USA
| | - Shelley A Hall
- Texas A&M Health Science Center, Dallas, TX, USA; Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX, USA; Baylor Scott & White Heart and Vascular Hospital, Dallas, TX, USA
| | - Teena Sam
- Department of Pharmacy, Baylor University Medical Center, Dallas, TX, USA.
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Mathew C, Milligan GP, Lemieux A, Colbert GB, Meyer DM, Alam A, Guerrero-Miranda CY. Risky Business: Angiotensin II Use In A Heartmate 3 LVAD Patient In The Setting Of Refractory Vasoplegia. J Card Fail 2022. [DOI: 10.1016/j.cardfail.2022.03.327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Cochran JM, Alam A, Guerrero-Miranda CY. Importance of right heart catheterization in advanced heart failure management. Rev Cardiovasc Med 2022; 23:12. [DOI: 10.31083/j.rcm2301012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/24/2021] [Accepted: 12/06/2021] [Indexed: 11/06/2022] Open
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van Zyl JS, Sam T, Clark DM, Felius J, Doss AK, Kerlee KR, Cheung ZO, Martits-Chalangari K, Jamil AK, Carey SA, Gottlieb RL, Guerrero-Miranda CY, Kale P, Hall SA. De novo tacrolimus extended-release tablets (LCPT) versus twice-daily tacrolimus in adult heart transplantation: Results of a single-center non-inferiority matched control trial. Clin Transplant 2021; 35:e14487. [PMID: 34529289 PMCID: PMC9285033 DOI: 10.1111/ctr.14487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/27/2021] [Accepted: 09/08/2021] [Indexed: 11/30/2022]
Abstract
Extended-release tacrolimus for prophylaxis of allograft rejection in orthotopic heart transplant (OHT) recipients is currently not FDA-approved. One such extended-release formulation of tacrolimus known as LCPT allows once-daily dosing and improves bioavailability compared to immediate-release tacrolimus (IR-tacrolimus). We compared the efficacy and safety of LCPT to IR-tacrolimus applied de novo in adult OHT recipients. Twenty-five prospective recipients on LCPT at our center from 2017 to 2019 were matched 1:2 with historical control recipients treated with IR-tacrolimus based on age, gender, and baseline creatinine. The primary composite outcome of death, acute cellular rejection, and/or new graft dysfunction within 1 year was compared using non-inferiority analysis. LCPT demonstrated non-inferiority to IR-tacrolimus, with a primary outcome risk reduction of 20% (90% CI: -40%, -.5%; non-inferiority P = .001). Tacrolimus trough levels peaked at 2-3 months and were higher in LCPT (median 14.5 vs. 12.7 ng/ml; P = .03) with similar dose levels (LCPT vs. IR-tacrolimus: .08 vs. .09 mg/kg/day; P = .33). Cardiovascular-related readmissions were reduced by 62% (P = .046) in LCPT patients. The complication rate per transplant admission and all-cause readmission rate did not differ significantly. These results suggest that LCPT is non-inferior in efficacy to IR-tacrolimus with a similar safety profile and improved bioavailability in OHT.
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Affiliation(s)
- Johanna S van Zyl
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA.,Texas A&M University College of Medicine Health Science Center, Dallas, Texas, USA
| | - Teena Sam
- Department of Pharmacy, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
| | - Donna M Clark
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Joost Felius
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA.,Texas A&M University College of Medicine Health Science Center, Dallas, Texas, USA
| | - Amanda K Doss
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Kacie R Kerlee
- Texas A&M University College of Medicine Health Science Center, Dallas, Texas, USA
| | - Zi-On Cheung
- Texas A&M University College of Medicine Health Science Center, Dallas, Texas, USA
| | | | - Aayla K Jamil
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA.,Texas A&M University College of Medicine Health Science Center, Dallas, Texas, USA
| | - Sandra A Carey
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
| | - Robert L Gottlieb
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA.,Texas A&M University College of Medicine Health Science Center, Dallas, Texas, USA.,Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA.,Division of Precision Medicine, Baylor University Medical Center, Dallas, Texas, USA
| | - Cesar Y Guerrero-Miranda
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA.,Texas A&M University College of Medicine Health Science Center, Dallas, Texas, USA.,Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
| | - Parag Kale
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA.,Texas A&M University College of Medicine Health Science Center, Dallas, Texas, USA.,Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
| | - Shelley A Hall
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA.,Texas A&M University College of Medicine Health Science Center, Dallas, Texas, USA.,Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
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Guerrero-Miranda CY, Hall SA. Rethinking the future with evolving technology: It's time to empower change in heart transplantation. Am J Transplant 2021; 21:453-455. [PMID: 32717109 DOI: 10.1111/ajt.16221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/06/2020] [Accepted: 07/09/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Cesar Y Guerrero-Miranda
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, Texas, USA.,Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, Texas, USA.,Department of Internal Medicine, Texas A&M Health Science Center, Dallas, Texas, USA
| | - Shelley A Hall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, Texas, USA.,Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, Texas, USA.,Department of Internal Medicine, Texas A&M Health Science Center, Dallas, Texas, USA
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Abstract
Patients with end-stage heart failure (HF) who have failed optimal medical therapy provide a unique set of challenges compared to the more prevalent population of patients with cardiogenic shock (CS) due to ST-segment elevation myocardial infarction. Progression from "preshock" into a refractory state of CS is associated with a dismal outcome due to difficulties with the patient's recognition, response to interventions, and candidacy for salvage options. Challenges include heterogeneity of CS (eg, different phenotypes, etiologies, duration, acuity of onset, hemodynamics, end-organ effects), lack of a universal definition of CS that is applicable to this patient population, and blunted hemodynamic response given the patient's prolonged compensatory state. Individuals with advanced HF in CS require a multidisciplinary team-based assessment regarding when to escalate from medical therapy into temporary mechanical circulatory support, and they need an eligibility evaluation to determine their candidacy for advanced therapy. In this review, we discuss the definition and clinical phenotypes of CS, classification of CS in advanced HF patients, the utility of temporary mechanical circulatory support, and the role of the CS team.
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Affiliation(s)
- Cesar Y Guerrero-Miranda
- BAYLOR SCOTT & WHITE RESEARCH INSTITUTE, DALLAS, TEXAS; BAYLOR UNIVERSITY MEDICAL CENTER, DALLAS, TEXAS; TEXAS A&M HEALTH SCIENCE CENTER, DALLAS, TEXAS
| | - Shelley A Hall
- BAYLOR SCOTT & WHITE RESEARCH INSTITUTE, DALLAS, TEXAS; BAYLOR UNIVERSITY MEDICAL CENTER, DALLAS, TEXAS; TEXAS A&M HEALTH SCIENCE CENTER, DALLAS, TEXAS
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Affiliation(s)
- Cesar Y Guerrero-Miranda
- Division of Cardiology, Department of Internal Medicine, Baylor University Medical Center, Dallas, TX.
| | - Shelley A Hall
- Division of Cardiology, Department of Internal Medicine, Baylor University Medical Center, Dallas, TX
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Guerrero-Miranda CY, Hall SA. Cardiac catheterization and percutaneous intervention procedures on extracorporeal membrane oxygenation support. Ann Cardiothorac Surg 2019; 8:123-128. [PMID: 30854321 DOI: 10.21037/acs.2018.11.08] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is used to support critically ill patients when conventional therapies have failed. ECMO has been available for four decades and has gained use as a rescue therapy in severe refractory hypoxic disorders and in patients with refractory cardiogenic shock (RCS). Over recent years, several percutaneous cardiac interventions and implant devices have been developed that are now used frequently in conjunction with ECMO in order to maintain organ perfusion. Here, we review the literature on VA-ECMO cannulation location, the use of VA-ECMO in interventions (e.g., coronary interventions and structural heart interventions) and percutaneous cardiac device implantation in VA-ECMO recipients with RCS.
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Affiliation(s)
- Cesar Y Guerrero-Miranda
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, TX, USA.,Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX, USA.,Department of Internal Medicine, Texas A & M University Health Science Center, Dallas, TX, USA
| | - Shelley A Hall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, TX, USA.,Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX, USA.,Department of Internal Medicine, Texas A & M University Health Science Center, Dallas, TX, USA
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Afzal A, Nisar T, Hoang J, Imbrock G, Cunningham L, Felius J, Joseph SM, Hall SA, Guerrero-Miranda CY. Assessment of Preoperative Echocardiographic Parameters as Predictors of Early Right Ventricular Failure in the Current Era of Continuous-Flow Left Ventricular Assist Devices. J Card Fail 2018. [DOI: 10.1016/j.cardfail.2018.07.407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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