Investigation of the safety and feasibility of AAV1/SERCA2a gene transfer in patients with chronic heart failure supported with a left ventricular assist device - the SERCA-LVAD TRIAL

The SERCA-LVAD trial was a phase 2a trial assessing the safety and feasibility of delivering an adeno-associated vector 1 carrying the cardiac isoform of the sarcoplasmic reticulum calcium ATPase (AAV1/SERCA2a) to adult chronic heart failure patients implanted with a left ventricular assist device. The SERCA-LVAD trial was one of a program of AAV1/SERCA2a cardiac gene therapy trials including CUPID1, CUPID 2 and AGENT trials. Enroled subjects were randomised to receive a single intracoronary infusion of 1 × 10¹³ DNase-resistant AAV1/SERCA2a particles or a placebo solution in a double-blinded design, stratified by presence of neutralising antibodies to AAV. Elective endomyocardial biopsy was performed at 6 months unless the subject had undergone cardiac transplantation, with myocardial samples assessed for the presence of exogenous viral DNA from the treatment vector. Safety assessments including ELISPOT were serially performed. Although designed as a 24 subject trial, recruitment was stopped after five subjects had been randomised and received infusion due to the neutral result from the CUPID 2 trial. Here we describe the results from the 5 patients at 3 years follow up, which confirmed that viral DNA was delivered to the failing human heart in 2 patients receiving gene therapy with vector detectable at follow up endomyocardial biopsy or cardiac transplantation. Absolute levels of detectable transgene DNA were low, and no functional benefit was observed. There were no safety concerns in this small cohort. This trial identified some of the challenges of performing gene therapy trials in this LVAD patient cohort which may help guide future trial design.

Home inotrope treatment for intractable heart failure following heart transplantation

A 49 year old man developed intractable heart failure three years after undergoing heart transplantation. Coronary angiography showed no evidence of graft vascular disease. An initial cardiac biopsy identified one episode of rejection which responded to augmented immunosuppressive treatment. The patient became inotrope dependent and has now survived at home for 22 months using an ambulatory delivery system for intravenous adrenaline (epinephrine), without significant complications. There has been a noticeable improvement in symptoms and left ventricular systolic performance, both clinically and as seen through echocardiographic and radiographic examination. This improvement was substantiated by the results of cardiac catheterisation, which showed a return to normal left ventricular filling pressure and cardiac output. The case is noteworthy because this treatment has allowed a patient who otherwise would have been hospital bound to return to the community. With the current shortage of organs, he would have been unlikely to receive a second transplant. The clinical features and outcome, and social, medicolegal, and financial issues are discussed.

Measurement of mycophenolate mofetil plasma levels after heart transplantation and a potential side effect of high levels

Mycophenolate mofetil (MMF) is gaining momentum in its use as an immunosuppressant and in the field of heart transplantation because of its efficacy and ease of use without a reported need to monitor plasma levels. We describe a case in which standard dosage of MMF (initially 1.5 g twice daily) produced elevated trough levels of mycophenolic acid (MPA). Although organ rejection was eradicated by the use of MMF, the patient developed severe anemia, which required repeated blood transfusions while the patient was on therapy. This case illustrates the potential value of monitoring MPA concentrations.

Significance of reverse transcription polymerase chain reaction in the detection of human cytomegalovirus gene transcripts in thoracic organ transplant recipients

BACKGROUND

Cytomegalovirus disease is a major cause of morbidity in transplant recipients. We have evaluated the clinical value of detecting viral mRNA transcripts for the diagnosis of active infection leading to disease in recipients of thoracic organ transplants.

METHODS

Blood samples from 10 transplant recipients were analyzed before transplantation and weekly after transplantation for 12 weeks. The profile of viral immediate-early, early, and late gene expression was determined by the reverse transcription polymerase chain reaction and compared with cytomegalovirus (pp65) antigenemia and host antibody status (serologic study).

RESULTS

Two patients showed no active cytomegalovirus infection, one had asymptomatic infection detected serologically and seven patients had development of symptomatic infection with a significant serologic change. Viral immediate-early mRNA transcript was detectable in all 10 patients, including the two with no active infection. Early and late gene expression occurred in seven patients who were all antigenemia positive and in whom disease developed. Of the seven patients with development of antigenemia, six showed viral early and late gene expression before pp65 antigenemia, whereas one patient showed antigenemia before early and late gene expression.

CONCLUSION

We have shown that the detection of viral early and late gene expression by reverse transcription polymerase chain reaction can act as diagnostic markers of cytomegalovirus disease with expression of early gene preceding the detection of antigenemia in most cases. In contrast, viral immediate early gene expression did not correlate with clinical infection. This diagnostic approach could be useful in the treatment of thoracic organ transplant recipients.

Medium term results of lung transplantation for end stage pulmonary sarcoidosis

BACKGROUND

Lung transplantation is an accepted therapeutic option for patients with end stage pulmonary sarcoidosis. However, the medium term outcome of transplantation in this patient group is unknown.

METHODS

This study was performed to evaluate our experience with lung transplantation for end stage pulmonary sarcoidosis. Between July 1988 and July 1997 12 patients (nine men) underwent lung transplantation for sarcoidosis at our institution. Ten underwent single lung transplantation and two double lung transplantation.

RESULTS

Survival at three and five years was 70% and 56%, respectively. Three patients developed obliterative bronchiolitis at six, 18, and 45 months. One died at the time of retransplantation. Sarcoid granulomas have recurred in the donor organ in three patients. In one the development of granulomas has been associated with clinical deterioration, necessitating retransplantation. Mean (SD) forced expiratory volumes in one second at three and five years were 1.37 (0.67) 1 and 1.34 (0.13) 1, respectively.

CONCLUSIONS

Lung transplantation is a viable option for patients with end stage pulmonary sarcoidosis. The medium term results are comparable with patients undergoing lung transplantation for other indications. Despite histological recurrence of sarcoidosis, the risk of clinically important recurrence is low.

Recurrence of recipient Langerhans' cell histiocytosis following bilateral lung transplantation

Langerhans' cell histiocytosis may cause irreversible respiratory failure due to progressive destruction of lung parenchyma and widespread cystic change. Transplantation offers a therapeutic option. A case is described of recurrence of Langerhans' cell histiocytosis which was associated with deterioration in lung function four years following bilateral lung transplantation. Patients transplanted for Langerhans' cell histiocytosis should be followed up with this complication in mind.

Influence of acute rejection episodes, HLA matching, and donor/recipient phenotype on the development of 'early' transplant-associated coronary artery disease

BACKGROUND

Transplant-associated coronary artery disease (TxCAD) is the manifestation of chronic rejection in the cardiac allograft. Both immunological and nonimmunological factors contribute to its development. Stratification by the time of development of TxCAD has not been considered previously for an extensive transplant series and may provide a means for apportioning relative risk factors appropriately. Specifically, TxCAD that develops early may have a pathogenesis different from TxCAD that develops later; ie, immunological factors play a more significant role in early development of TxCAD compared with later forms of the disease or in recipients where it has not been found.

METHODS AND RESULTS

Between 1980 and 1994, 550 heart transplant recipients with postmortem data or yearly angiograms, donor:recipient serological HLA typing, and biopsy data were reviewed. Recipients were divided into four groups: Very Early (<1 year), Early (1-2 years), Late (3-14 years), and None (clear angio >3 years). There was a significant association between the number of histologically proven acute rejection episodes within 3 months and at 1 year and the development of early TxCAD. The number of acute rejection episodes within 3 months and 1 year is also significantly related to freedom of development of TxCAD. There was no significant association between the mean number of mismatches for Class I or Class II antigens, nor could any Class I/II phenotype for recipient or donor be identified that exerted a protective or deleterious effect. A lack of any association or trend with HLA data is demonstrated.

CONCLUSIONS

These differences in pathogenesis between early and late TxCAD help define the importance of acute rejection in the etiology of chronic cardiac rejection. Stratification by time of development of TxCAD may provide further insight into defining the relative importance of other risk factors associated with the development of TxCAD. The lack of association with HLA data is discussed.

An evaluation of nebulized prostacyclin in patients with primary and secondary pulmonary hypertension

AIMS

To investigate the response to inhaled prostacyclin in patients with primary and secondary pulmonary hypertension and to compare its effects to those of intravenous prostacyclin and inhaled nitric oxide.

METHODS AND RESULTS

Twelve patients with pulmonary hypertension (seven primary and five secondary) were studied. All patients had a pulmonary artery balloon flotation catheter inserted into the proximal pulmonary artery and radial arterial line. Prostacyclin was nebulized with 81.min-1 of oxygen and administered in doses increasing from 15 to 50 ng.kg-1.min-1 via a facemask. Eight of these patients also received intravenous prostacyclin in doses of 1 to 5 ng.kg-1.min-1 and nitric oxide in doses of 10 to 100 ppm via a facemask. Haemodynamic measurements were taken during each treatment. In the 12 patients, nebulized prostacyclin produced a significant reduction in mean pulmonary artery pressure from 56 +/- 5 to 45 +/- 4 mmHg (P = 0.0001). The pulmonary vascular resistance decreased by 38% from 964 +/- 169 to 595 +/- 116 dyne.s-1.cm-5 (P = 0.0001). Direct comparison with inhaled nitric oxide and intravenous prostacyclin in eight patients demonstrated that nebulized prostacyclin produced a greater fall in mean pulmonary artery pressure than the other two agents without any significant effect on systemic arterial pressure.

CONCLUSION

Nebulized prostacyclin appears to be more effective at reducing pulmonary artery pressure in patients with pulmonary hypertension when compared to intravenous prostacyclin and inhaled nitric oxide. This could have important clinical implications for the management of patients with pulmonary hypertensions.

Determinants of transplant-related coronary calcium detected by ultrafast computed tomography scanning

Coronary calcium detected by ultrafast computed tomography (CT) has been shown to be a marker of coronary artery disease in heart transplant recipients. The objective of this study was to examine the possible determinants of coronary calcium after heart transplantation. Over a 15-month period, 102 consecutive cardiac transplant recipients (mean age 53 years, 88 men) underwent ultrafast CT scanning of the heart, in addition to coronary angiography, to determine coronary calcium score on their annual follow-up (a median of 4.6 years [range 63 days to 9.1 years] after transplant). The following data were also recorded: the recipient's sex and date of birth, date of transplantation, date of ultrafast computed tomography and coronary angiography; recipient pretransplant diagnosis, history of diabetes mellitus and systemic hypertension, fasting lipid profile, immunosuppression, number of rejection episodes, and donor organ ischemic time. Forty six patients (45.1%) had total calcium scores >0 and 41 (40.2%) had at least 1 major coronary with angiographic narrowing >24%. On univariate analysis, coronary calcium was significantly associated with dyslipoproteinemia, total cholesterol was >6.0 mmol/L (240 mg/dl), triglycerides were >3.0 mmol/L (265 mg/dl), and lipoprotein(a) >30 mg/ dl; > or =25% angiographic disease was significantly associated with coronary calcium and dyslipoproteinemia. Logistic regression revealed that dyslipoproteinemia, systemic hypertension, and donor ischemic time were significant predictors of coronary calcium in transplanted hearts. We conclude that the prevalence of coronary calcium in heart transplant recipients is high and is related to recipient dyslipoproteinemia, systemic hypertension, and donor organ ischemic time.

Early experience with single lung transplantation for emphysema with simultaneous volume reduction of the contralateral lung

OBJECTIVE

Single lung transplantation (SLT) for emphysema has given satisfactory long term results in most patients. The mediastinal shift caused by the native emphysematous lung may require further surgical intervention in selected cases.

METHODS

We report a technique of simultaneous SLT and volume reduction of the contralateral lung in 4 patients with end stage respiratory failure secondary to emphysema. There were two right and two left SLT, performed in two male and two female patients. Their mean age was 52.2 (S.D. 4) years (range between 41 and 57 years) and the ischaemia time averaged 255.6 (S.D. 16) min (range between 225 and 255 min). The volume of the contralateral lung was reduced using staples. The stapled lines were buttressed by the donors pericardium.

RESULTS

Their were no operative related complications apart from air leak which settled spontaneously within 5 days postoperatively. Teh pre-operative FEVI showed a mean value of 0.57 (S.D. 0.1) L (17.2% (S.D. 2) of the predicted) which improved to 1.79 (S.D. 0.4) L (58.2% (S.D. 8) of the predicted) at last follow up (P < 0.005). Radiological examinations at 1 year showed central mediastinum with satisfactory respiratory function.

CONCLUSION

We conclude that this technique can be performed for patients with emphysema without increase in the operative morbidity and with good early respiratory function. Further follow up is required to assess the long term results of this procedure.

The prognostic significance of non-invasive cardiac tests in heart transplant recipients

The long-term mortality and morbidity of cardiac transplant recipients is related to their subsequent development of accelerated coronary atheroma and its complications. Coronary angiography was compared with non-invasive clinical assessment to see which was better in predicting clinical outcome. Ninety-one consecutive transplant recipients (mean age 53 years), in whom investigations had been performed (exercise electrocardiography, rest and exercise radionuclide ventriculography, 2-D echocardiography and coronary angiography), were followed up for a mean period of 2.1 years. Eighteen patients had 31 cardiac events. There were five cardiac-related deaths, 17 myocardial infarctions and/or onsets of heart failure, eight percutaneous transluminal coronary angioplasties and one coronary artery bypass graft. With cardiac event-free survival as the dependent variable and the results of the above investigations as independent variables, a series of univariate, bivariate and regression analyses were performed. On bivariate analysis, an echocardiographic ejection fraction of > 60% significantly predicted both survival free of myocardial infarction and/or heart failure and/or cardiac death and survival free of any cardiac event (P = 0.001 for both). Absence of coronary angiographic disease (both of < 25% and of < 50% luminal narrowing in any vessel) significantly predicted survival free of any cardiac event (P = 0.00004 and 0.015, respectively). Neither radionuclide ventriculography nor exercise electrocardiography were significant predictors of event free survival. In conclusion, echocardiography is at least as important as coronary angiography in the follow-up and prognostic assessment of cardiac transplant recipients.