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Holzhauser L, DeFilippis EM, Nikolova A, Byku M, Contreras JP, De Marco T, Hall S, Khush KK, Vest AR. The End of Endomyocardial Biopsy?: A Practical Guide for Noninvasive Heart Transplant Rejection Surveillance. JACC. HEART FAILURE 2023; 11:263-276. [PMID: 36682960 DOI: 10.1016/j.jchf.2022.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/31/2022] [Accepted: 11/03/2022] [Indexed: 01/13/2023]
Abstract
Noninvasive heart transplant rejection surveillance using gene expression profiling (GEP) to monitor immune activation is widely used among heart transplant programs. With the new development of donor-derived cell-free DNA (dd-cfDNA) assays, more programs are transitioning to a predominantly noninvasive rejection surveillance protocol with a reduced frequency of endomyocardial biopsies. As a result, many practical questions arise that potentially delay implementation of these valuable new tools. The purpose of this review is to provide practical guidance for clinicians transitioning toward a less invasive acute rejection monitoring protocol after heart transplantation, and to answer 10 common questions about the GEP and dd-cfDNA assays. Evidence supporting GEP and dd-cfDNA testing is reviewed, as well as guidance on test interpretation and future directions.
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Affiliation(s)
- Luise Holzhauser
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ersilia M DeFilippis
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Andriana Nikolova
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Mirnela Byku
- Department of Cardiology, University of North Carolina in Chapel Hill, North Carolina, USA
| | | | - Teresa De Marco
- Division of Cardiology, University of California, San Francisco, California, USA
| | - Shelley Hall
- Baylor University Medical Center, Dallas, Texas, USA
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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Liu Z, Perry LA, Penny-Dimri JC, Handscombe M, Overmars I, Plummer M, Segal R, Smith JA. Elevated Cardiac Troponin to Detect Acute Cellular Rejection After Cardiac Transplantation: A Systematic Review and Meta-Analysis. TRANSPLANT INTERNATIONAL : OFFICIAL JOURNAL OF THE EUROPEAN SOCIETY FOR ORGAN TRANSPLANTATION 2022; 35:10362. [PMID: 35755856 PMCID: PMC9215116 DOI: 10.3389/ti.2022.10362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 05/17/2022] [Indexed: 11/13/2022]
Abstract
Cardiac troponin is well known as a highly specific marker of cardiomyocyte damage, and has significant diagnostic accuracy in many cardiac conditions. However, the value of elevated recipient troponin in diagnosing adverse outcomes in heart transplant recipients is uncertain. We searched MEDLINE (Ovid), Embase (Ovid), and the Cochrane Library from inception until December 2020. We generated summary sensitivity, specificity, and Bayesian areas under the curve (BAUC) using bivariate Bayesian modelling, and standardised mean differences (SMDs) to quantify the diagnostic relationship of recipient troponin and adverse outcomes following cardiac transplant. We included 27 studies with 1,684 cardiac transplant recipients. Patients with acute rejection had a statistically significant late elevation in standardised troponin measurements taken at least 1 month postoperatively (SMD 0.98, 95% CI 0.33–1.64). However, pooled diagnostic accuracy was poor (sensitivity 0.414, 95% CrI 0.174–0.696; specificity 0.785, 95% CrI 0.567–0.912; BAUC 0.607, 95% CrI 0.469–0.723). In summary, late troponin elevation in heart transplant recipients is associated with acute cellular rejection in adults, but its stand-alone diagnostic accuracy is poor. Further research is needed to assess its performance in predictive modelling of adverse outcomes following cardiac transplant. Systematic Review Registration: identifier CRD42021227861
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Affiliation(s)
- Zhengyang Liu
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Luke A Perry
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Jahan C Penny-Dimri
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Michael Handscombe
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Isabella Overmars
- Infection and Immunity Theme, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Mark Plummer
- Department of Intensive Care Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia.,Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Reny Segal
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, VIC, Australia.,Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Julian A Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
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Cruz CBBV, Hajjar LA, Bacal F, Lofrano-Alves MS, Lima MSM, Abduch MC, Vieira MLC, Chiang HP, Salviano JBC, da Silva Costa IBS, Fukushima JT, Sbano JCN, Mathias W, Tsutsui JM. Usefulness of speckle tracking echocardiography and biomarkers for detecting acute cellular rejection after heart transplantation. Cardiovasc Ultrasound 2021; 19:6. [PMID: 33422079 PMCID: PMC7797113 DOI: 10.1186/s12947-020-00235-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/21/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute cellular rejection (ACR) is a major complication after heart transplantation. Endomyocardial biopsy (EMB) remains the gold standard for its diagnosis, but it has concerning complications. We evaluated the usefulness of speckle tracking echocardiography (STE) and biomarkers for detecting ACR after heart transplantation. METHODS We prospectively studied 60 transplant patients with normal left and right ventricular systolic function who underwent EMB for surveillance 6 months after transplantation. Sixty age- and sex-matched healthy individuals constituted the control group. Conventional echocardiographic parameters, left ventricular global longitudinal, radial and circumferential strain (LV-GLS, LV-GRS and LV-GCS, respectively), left ventricular systolic twist (LV-twist) and right ventricular free wall longitudinal strain (RV-FWLS) were analyzed just before the procedure. We also measured biomarkers at the same moment. RESULTS Among the 60 studied patients, 17 (28%) had severe ACR (grade ≥ 2R), and 43 (72%) had no significant ACR (grade 0 - 1R). The absolute values of LV-GLS, LV-twist and RV-FWLS were lower in transplant patients with ACR degree ≥ 2 R than in those without ACR (12.5% ± 2.9% vs 14.8% ± 2.3%, p=0.002; 13.9° ± 4.8° vs 17.1° ± 3.2°, p=0.048; 16.6% ± 2.9% vs 21.4%± 3.2%, p < 0.001; respectively), while no differences were observed between the LV-GRS or LV-GCS. All of these parameters were lower in the transplant group without ACR than in the nontransplant control group, except for the LV-twist. Cardiac troponin I levels were significantly higher in patients with significant ACR than in patients without significant ACR [0.19 ng/mL (0.09-1.31) vs 0.05 ng/mL (0.01-0.18), p=0.007]. The combination of troponin with LV-GLS, RV-FWLS and LV-Twist had an area under curve for the detection of ACR of 0.80 (0.68-0.92), 0.89 (0.81-0.93) and 0.79 (0.66-0.92), respectively. CONCLUSION Heart transplant patients have altered left ventricular dynamics compared with control individuals. The combination of troponin with strain parameters had higher accuracy for the detection of ACR than the isolated variables and this association might select patients with a higher risk for ACR who will benefit from an EMB procedure in the first year after heart transplantation.
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Affiliation(s)
- Cecilia Beatriz Bittencourt Viana Cruz
- Heart Institute (InCor), University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, 05403-000, Brazil. .,Fleury Medicine & Health, São Paulo, Brazil.
| | - Ludhmila A Hajjar
- Heart Institute (InCor), University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, 05403-000, Brazil
| | - Fernando Bacal
- Heart Institute (InCor), University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, 05403-000, Brazil
| | - Marco S Lofrano-Alves
- Heart Institute (InCor), University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, 05403-000, Brazil
| | - Márcio S M Lima
- Heart Institute (InCor), University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, 05403-000, Brazil.,Fleury Medicine & Health, São Paulo, Brazil
| | - Maria C Abduch
- Heart Institute (InCor), University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, 05403-000, Brazil
| | - Marcelo L C Vieira
- Heart Institute (InCor), University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, 05403-000, Brazil
| | - Hsu P Chiang
- Heart Institute (InCor), University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, 05403-000, Brazil.,Fleury Medicine & Health, São Paulo, Brazil
| | - Juliana B C Salviano
- Heart Institute (InCor), University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, 05403-000, Brazil
| | | | - Julia Tizue Fukushima
- Heart Institute (InCor), University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, 05403-000, Brazil
| | - Joao C N Sbano
- Heart Institute (InCor), University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, 05403-000, Brazil.,Fleury Medicine & Health, São Paulo, Brazil
| | - Wilson Mathias
- Heart Institute (InCor), University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, 05403-000, Brazil.,Fleury Medicine & Health, São Paulo, Brazil
| | - Jeane M Tsutsui
- Heart Institute (InCor), University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, 05403-000, Brazil.,Fleury Medicine & Health, São Paulo, Brazil
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Long B, Brady WJ, Gragossian A, Koyfman A, Gottlieb M. A primer for managing cardiac transplant patients in the emergency department setting. Am J Emerg Med 2021; 41:130-138. [PMID: 33440325 DOI: 10.1016/j.ajem.2020.12.071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 12/26/2020] [Accepted: 12/27/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Cardiac transplant is an effective long-term management option for several severe cardiac diseases. These cardiac transplant patients may present to the emergency department with a range of issues involving the cardiac transplantation, including complications due to their transplant as well as altered presentations of disease resulting from their transplant. OBJECTIVE This narrative review provides a focused guide to the evaluation and management of patients with cardiac transplantation and its complications. DISCUSSION Cardiac transplant is an effective therapy for end-stage heart failure. A transplanted heart varies both anatomically and physiologically from a native heart. Several significant complications may occur. Graft failure, rejection, and infection are common causes of morbidity and mortality within the first year of transplant. As these patients are on significant immunosuppressive medication regimens, they are at risk of infection, but inadequate immunosuppression increases the risk of acute rejection. A variety of dysrhythmias such as atrial fibrillation and ventricular dysrhythmias may occur. These patients are also at risk of acute coronary syndrome, cardiac allograft vasculopathy, and medication adverse events. Importantly, patients with acute coronary syndrome can have an altered presentation with the so-called "painless" myocardial infarction. Consultation with the transplant physician is recommended, if available, for these patients to assist in evaluation and management. CONCLUSIONS An understanding of the presentations and various complications that may affect patients with cardiac transplant will assist emergency clinicians in the care of these patients.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
| | - William J Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, United States of America.
| | - Alin Gragossian
- The Mt Sinai Hospital, Institute for Critical Care Medicine, New York, NY, United States of America
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, United States of America
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
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Non-invasive cardiac allograft rejection surveillance: reliability and clinical value for prevention of heart failure. Heart Fail Rev 2020; 26:319-336. [PMID: 32889634 DOI: 10.1007/s10741-020-10023-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2020] [Indexed: 01/04/2023]
Abstract
Allograft rejection-related acute and chronic heart failure (HF) is a major cause of death in heart transplant recipients. Given the deleterious impact of late recognized acute rejection (AR) or non-recognized asymptomatic antibody-mediated rejection on short- and long-term allograft function improvement of AR surveillance and optimization of action strategies for confirmed AR can prevent AR-related allograft failure and delay the development of cardiac allograft vasculopathy, which is the major cause for HF after the first posttransplant year. Routine non-invasive monitoring of cardiac function can improve both detection and functional severity grading of AR. It can also be helpful in guiding the anti-AR therapy and timing of routine surveillance endomyocardial biopsies (EMBs). The combined use of EMBs with non-invasive technologies and methods, which allow detection of subclinical alterations in myocardial function (e.g., tissue Doppler imaging and speckle-tracking echocardiography), reveal alloimmune activation (e.g., screening of complement-activating donor-specific antibodies and circulating donor-derived cell-free DNA) and help in predicting the imminent risk of immune-mediated injury (e.g., gene expression profiling, screening of non-HLA antibodies, and circulating donor-derived cell-free DNA), can ensure the best possible surveillance and management of AR. This article gives an overview of the current knowledge about the reliability and clinical value of non-invasive cardiac allograft AR surveillance. Particular attention is focused on the potential usefulness of non-invasive tools and techniques for detection and functional grading of early and late ARs in asymptomatic patients. Overall, the review aimed to provide a theoretical and practical basis for those engaged in this particularly demanding up-to-date topic.
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Loungani RS, Mentz RJ, Agarwal R, DeVore AD, Patel CB, Rogers JG, Russell SD, Felker GM. Biomarkers in Advanced Heart Failure: Implications for Managing Patients With Mechanical Circulatory Support and Cardiac Transplantation. Circ Heart Fail 2020; 13:e006840. [PMID: 32660322 DOI: 10.1161/circheartfailure.119.006840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Biomarkers have a well-defined role in the diagnosis and management of chronic heart failure, but their role in patients with left ventricular assist devices and cardiac transplant is uncertain. In this review, we summarize the available literature in this patient population, with a focus on clinical application. Some ubiquitous biomarkers, for example, natriuretic peptides and cardiac troponin, may assist in the diagnosis of left ventricular assist device complications and transplant rejection. Novel biomarkers focused on specific pathological processes, such as left ventricular assist device thrombosis and profiling of leukocyte activation, continue to be developed and show promise in altering the management of the advanced heart failure patient. Few biomarkers at this time have been assessed with sufficient scrutiny to warrant broad, universal application, but encouraging limited data and large potential for impact should prompt ongoing investigation.
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Affiliation(s)
- Rahul S Loungani
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Richa Agarwal
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Adam D DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Chetan B Patel
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Joseph G Rogers
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Stuart D Russell
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, NC
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Indicators of impending pig kidney and heart xenograft failure: Relevance to clinical organ xenotransplantation - Review article. Int J Surg 2019; 70:84-91. [DOI: 10.1016/j.ijsu.2019.08.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 08/03/2019] [Accepted: 08/19/2019] [Indexed: 12/13/2022]
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Nakamura Y, Saito S, Miyagawa S, Yoshikawa Y, Hata H, Yoshioka D, Toda K, Sawa Y. Perioperative ischaemic reperfusion injury and allograft function in the early post-transplantation period. Interact Cardiovasc Thorac Surg 2019; 29:230–236. [PMID: 30919896 DOI: 10.1093/icvts/ivz086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/08/2019] [Accepted: 02/21/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Ischaemic reperfusion injury (IRI) is an inevitable complication of heart transplantation (HTX) and is observed as a pathological finding in biopsies from transplanted allografts. The aim of this study was to evaluate the severity of IRI and determine the clinical outcomes of HTX in patients with severe IRI. METHODS We enrolled 74 consecutive patients who had undergone HTX since 2007. Endomyocardial biopsy samples were obtained from the right ventricle of the transplanted heart. IRI was graded as 'trivial', 'mild', 'moderate' or 'severe' according to the extent of IRI-specific findings in the samples. The cohort was divided into a moderate-to-severe IRI group with 21 patients [IRI(+)] and a low-grade group with 53 patients [IRI(-)]. RESULTS The frequency of mechanical circulatory support and duration of catecholamine dependence in the early postoperative period were significantly higher in the IRI(+) group compared to the IRI(-) group. However, overall survival after HTX and mid-term cardiac allograft function were not significantly different between the groups. Among perioperative factors, cardiac ischaemic time was significantly different between the groups [IRI(-) vs IRI(+), 199 ± 38 min vs 239 ± 39 min; P < 0.001]. Incremental increases in cardiac ischaemic time were correlated with increases in IRI severity. Serum troponin T levels 3 h after donor heart reperfusion was significantly correlated with cardiac ischaemic time (r = 0.418, P = 0.0007). CONCLUSIONS IRI is associated with a complicated clinical course in the early post-HTX period due to temporary deterioration of allograft function. This may be attributable to myocardial stunning caused by long donor heart ischaemic time during HTX.
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Affiliation(s)
- Yuki Nakamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shunsuke Saito
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasushi Yoshikawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroki Hata
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Outcomes of Acute Myocardial Infarction in Heart Transplant Recipients. Am J Cardiol 2018; 122:2080-2085. [PMID: 30301541 DOI: 10.1016/j.amjcard.2018.08.060] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 08/17/2018] [Accepted: 08/23/2018] [Indexed: 11/20/2022]
Abstract
Heart transplantation (HT) recipients represent a growing patient population. Although mechanisms might differ, coronary artery disease is an important cause of morbidity in this group. Limited data are available on the outcomes of acute myocardial infarction (AMI) in HT in comparison to general population (non-HT). The study population was extracted from the National Readmissions Data 2014 using International Classification of Diseases, Ninth Revision, Clinical Modification codes for AMI and HT. The study outcomes included in-hospital all-cause mortality, length of hospital stay (LOS), cardiogenic shock, acute kidney injury, the likelihood of receiving invasive left-sided cardiac catheterization with and/or without percutaneous coronary intervention (PCI) and 30-day readmission rates. A total of 259,794 discharges with a principal diagnosis of AMI were identified, in which 789 had a history of HT. In comparison to non-HT, HT group was associated with longer LOS (5.9 vs 4.9 days, p <0.01), more cardiogenic shock (8.8% vs 6.4%, p <0.01), more acute kidney injury (26.2% vs 17.6%, p <0.01), less catheterization (59.7% vs 75.1%, p <0.01), less use of PCI (35.2% vs 50.0%, p <0.01), and higher 30-day readmission rate (21.3% vs 14.4%, p <0.01). However, there was no statistically significant difference in all-cause mortality (6.8% vs 5.4%, p = 0.07). In conclusion, compared with non-HT, HT with AMI was associated with longer LOS, more in-hospital morbidity, lower likelihood of receiving invasive treatment (including PCI), and higher 30-day readmission rates. There was no significant difference in all-cause mortality.
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10
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Wong TC, McNamara DM. Imaging-Based Surveillance for Graft Rejection Following Heart Transplantation: Ready for Prime Time? JACC Cardiovasc Imaging 2018; 12:1615-1617. [PMID: 29680340 DOI: 10.1016/j.jcmg.2018.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 04/02/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Timothy C Wong
- Department of Medicine, Division of Cardiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Cardiovascular Magnetic Resonance Center, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Dennis M McNamara
- Department of Medicine, Division of Cardiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Center for Heart Failure Research, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Habertheuer A, Korutla L, Rostami S, Reddy S, Lal P, Naji A, Vallabhajosyula P. Donor tissue-specific exosome profiling enables noninvasive monitoring of acute rejection in mouse allogeneic heart transplantation. J Thorac Cardiovasc Surg 2018; 155:2479-2489. [PMID: 29499866 DOI: 10.1016/j.jtcvs.2017.12.125] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 11/14/2017] [Accepted: 12/07/2017] [Indexed: 12/31/2022]
Abstract
OBJECTIVE In heart transplantation, there is a critical need for development of biomarkers to noninvasively monitor cardiac allografts for immunologic rejection or injury. Exosomes are tissue-specific nanovesicles released into circulation by many cell types. Their profiles are dynamic, reflecting conditional changes imposed on their tissue counterparts. We proposed that a transplanted heart releases donor-specific exosomes into the recipient's circulation that are conditionally altered during immunologic rejection. We investigated this novel concept in a rodent heterotopic heart transplantation model. MATERIALS AND METHODS Full major histocompatibility mismatch (BALB/c [H2-Kd] into C57BL/6 [H2-Kb]) heterotopic heart transplantation was performed in 2 study arms: Rejection (n = 64) and Maintenance (n = 28). In the Rejection arm, immunocompetent recipients fully rejected the donor heart, whereas in the Maintenance arm, immunodeficient recipients (C57BL/6 PrkdcSCID) accepted the allograft. Recipient plasma exosomes were isolated and a donor heart-specific exosome signal was characterized on the nanoparticle detector for time-specific profile changes using anti-H2-Kd antibody quantum dot. RESULTS In the Maintenance arm, allografts were viable throughout follow-up of 30 days, with histology confirming absence of rejection or injury. Time course analysis (days 1, 2, 3, 4, 5, 7, 9, 11, 15, and 30) showed that total plasma exosome concentration (P = .157) and donor heart exosome signal (P = .538) was similar between time points. In the Rejection arm, allografts were universally rejected (median, day 11). Total plasma exosome quantity and size distribution were similar between follow-up time points (P = .278). Donor heart exosome signals peaked on day 1, but significantly decreased by day 2 (P = 2 × 10-4) and day 3 (P = 3.3 × 10-6), when histology showed grade 0R rejection. The receiver operating characteristic curve for a binary separation of the 2 study arms (Maintenance vs Rejection) demonstrated that a donor heart exosome signal threshold < 0.3146 was 91.4% sensitive and 95.8% specific for diagnosis of early acute rejection. CONCLUSIONS Transplant heart exosome profiling enables noninvasive monitoring of early acute rejection with high accuracy. Translation of this concept to clinical settings might enable development of a novel biomarker platform for allograft monitoring in transplantation diagnostics.
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Affiliation(s)
- Andreas Habertheuer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Laxminarayana Korutla
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Susan Rostami
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Sanjana Reddy
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Priti Lal
- Department of Pathology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Ali Naji
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
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13
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Fitzsimons S, Evans J, Parameshwar J, Pettit SJ. Utility of troponin assays for exclusion of acute cellular rejection after heart transplantation: A systematic review. J Heart Lung Transplant 2017; 37:631-638. [PMID: 29426716 DOI: 10.1016/j.healun.2017.12.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/06/2017] [Accepted: 12/05/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Acute cellular rejection (ACR) is a common complication in the first year after heart transplantation (HT). Routine surveillance for ACR is undertaken by endomyocardial biopsy (EMB). Measurement of cardiac troponins (cTn) in serum is an established diagnostic test of cardiac myocyte injury. This systematic review aimed to determine whether cTn measurement could be used to diagnose or exclude ACR. METHODS PubMed, Google Scholar and the JHLT archive were searched for studies reporting the result of a cTn assay and a paired surveillance EMB. Significant ACR was defined as International Society for Heart and Lung Transplantataion (ISHLT) Grade ≥3a/≥2R. Considerable heterogeneity between studies precluded quantitative meta-analysis. Individual study sensitivity and specificity data were examined and used to construct a pooled hierarchical summary receiver-operator characteristic (ROC) curve. RESULTS Twelve studies including 993 patients and 3,803 EMBs, of which 3,729 were paired with cTn levels, had adequate data available for inclusion. The overall rate of significant ACR was 12%. There was wide variation in diagnostic performance. cTn assays demonstrated sensitivity of 8% to 100% and specificity of 13% to 88% for detection of ACR. The positive predictive value (PPV) was low but the negative predictive value (NPV) was relatively high (79% to 100%). High-sensitivity cTn assays had greater sensitivity and NPV than conventional cTn assays for detection of ACR (sensitivity: 82% to 100% vs 8% to 77%; NPV: 97% to 100% vs 81% to 95%, respectively). CONCLUSIONS cTn assays do not have sufficient specificity to diagnose ACR in place of EMB. However, hs-cTn assays may have sufficient sensitivity and negative predictive value to exclude ACR and limit the need for surveillance EMB. Further research is required to assess this strategy.
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Affiliation(s)
- Sarah Fitzsimons
- Transplant Unit, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK; Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
| | - Jonathan Evans
- Transplant Unit, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK; Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jayan Parameshwar
- Transplant Unit, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK; Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephen J Pettit
- Transplant Unit, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK; Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Abstract
Despite major advances in the medical care of patients following heart transplantation (HTx) and a steady increase in long-term survival, allograft surveillance is still based on endomyocardial biopsy, the gold standard since the 1970s. This invasive procedure calls for less burdening and more cost-effective approaches. In recent years, impressive progress has been made in utilizing blood-based biomarkers for the diagnosis and management of diseases in a variety of fields. Hence, a number of trials have been performed testing the usefulness of circulating molecules or other technical methods to overcome the need for surveillance myocardial biopsy in HTx patients. Here, we review current approaches and the state of research on novel biomarkers for the management of patients following heart transplantation.
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Starling RC, Stehlik J, Baran DA, Armstrong B, Stone JR, Ikle D, Morrison Y, Bridges ND, Putheti P, Strom TB, Bhasin M, Guleria I, Chandraker A, Sayegh M, Daly KP, Briscoe DM, Heeger PS. Multicenter Analysis of Immune Biomarkers and Heart Transplant Outcomes: Results of the Clinical Trials in Organ Transplantation-05 Study. Am J Transplant 2016; 16:121-36. [PMID: 26260101 PMCID: PMC4948061 DOI: 10.1111/ajt.13422] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 05/20/2015] [Accepted: 06/14/2015] [Indexed: 01/25/2023]
Abstract
Identification of biomarkers that assess posttransplant risk is needed to improve long-term outcomes following heart transplantation. The Clinical Trials in Organ Transplantation (CTOT)-05 protocol was an observational, multicenter, cohort study of 200 heart transplant recipients followed for the first posttransplant year. The primary endpoint was a composite of death, graft loss/retransplantation, biopsy-proven acute rejection (BPAR), and cardiac allograft vasculopathy (CAV) as defined by intravascular ultrasound (IVUS). We serially measured anti-HLA- and auto-antibodies, angiogenic proteins, peripheral blood allo-reactivity, and peripheral blood gene expression patterns. We correlated assay results and clinical characteristics with the composite endpoint and its components. The composite endpoint was associated with older donor allografts (p < 0.03) and with recipient anti-HLA antibody (p < 0.04). Recipient CMV-negativity (regardless of donor status) was associated with BPAR (p < 0.001), and increases in plasma vascular endothelial growth factor-C (OR 20; 95%CI:1.9-218) combined with decreases in endothelin-1 (OR 0.14; 95%CI:0.02-0.97) associated with CAV. The remaining biomarkers showed no relationships with the study endpoints. While suboptimal endpoint definitions and lower than anticipated event rates were identified as potential study limitations, the results of this multicenter study do not yet support routine use of the selected assays as noninvasive approaches to detect BPAR and/or CAV following heart transplantation.
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Affiliation(s)
| | - Josef Stehlik
- University of Utah Health Sciences Center, Salt Lake City UT
| | | | | | | | | | - Yvonne Morrison
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville MD
| | - Nancy D. Bridges
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville MD
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16
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Ahn KT, Choi JO, Lee GY, Park HD, Jeon ES. Usefulness of high-sensitivity troponin I for the monitoring of subclinical acute cellular rejection after cardiac transplantation. Transplant Proc 2015; 47:504-10. [PMID: 25769598 DOI: 10.1016/j.transproceed.2014.10.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 10/15/2014] [Accepted: 10/28/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND There are conflicting data about the role of cardiac troponin I (cTnI) as determined by means of conventional methods for the prediction of acute rejection after heart transplantation (HT). The purpose of this study was to evaluate whether cTnI as measured by means of the early prototype high-sensitivity assay (hs-cTnI) can predict acute rejection episode after HT compared with grade of rejection in endomyocardial biopsy (EMB). METHODS This was a single-center cross-sectional study evaluating cTnI levels with the use of both hs-cTnI and current less sensitive conventional cTnI (conv-cTnI) assays measured at the time of EMB after HT. We calculated an index ratio of observed cTnI to expected mean cTnI for each individual patient defined as the mean cTnI measurements at EMB 60 days after HT. RESULTS A total of 252 biopsies from 47 patients were included in this study. In the multivariable mixed model analysis in relation to the presence of acute rejection 60 days after HT, hs-cTnI level was significantly related to the presence of rejection (P = .010). The hs-cTnI ratio index was significantly higher at the time of rejection (median, 1.37; interquartile range [IQR], 1.23-2.88) compared with those without rejection (median, 0.90; IQR, 0.51-1.16; P < .001). In receiver operating characteristic curve analysis, an hs-cTnI ratio index of ≥1.17 could predict the acute rejection with a sensitivity of 82.4% and a specificity of 77.1%. CONCLUSIONS An increased hs-cTnI ratio index was significantly related to rejection episodes. Serial monitoring of hs-cTnI and comparing it with the values without rejection might be useful for the detection of acute rejection after HT.
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Affiliation(s)
- K T Ahn
- Division of Cardiology, Cardiac and Vascular Centers, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - J-O Choi
- Division of Cardiology, Cardiac and Vascular Centers, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - G Y Lee
- Division of Cardiology, Cardiac and Vascular Centers, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - H-D Park
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - E-S Jeon
- Division of Cardiology, Cardiac and Vascular Centers, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Repeated measurements of NT-pro-B-type natriuretic peptide, troponin T or C-reactive protein do not predict future allograft rejection in heart transplant recipients. Transplantation 2015; 99:580-5. [PMID: 25136844 DOI: 10.1097/tp.0000000000000378] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Studies on the prognostic value of serial biomarker assays for future occurrence of allograft rejection (AR) are scarce. We examined whether repeated measurements of NT-pro-B-type natriuretic peptide (NT-proBNP), troponin T (TropT) and C-reactive protein (CRP) predict AR. METHODS From 2005 to 2010, 77 consecutive heart transplantation (HTx) recipients were included. The NT-proBNP, TropT, and CRP were measured at 16 ± 4 (mean ± standard deviation) consecutive routine endomyocardial biopsy surveillance visits during the first year of follow-up. Allograft rejection was defined as International Society for Heart and Lung Transplantation (ISHLT) grade 2R or higher at endomyocardial biopsy. Joint modeling was used to assess the association between repeated biomarker measurements and occurrence of future AR. Joint modeling accounts for dependence among repeated observations in individual patients. RESULTS The mean age of the patients at HTx was 49 ± 9.2 years, and 68% were men. During the first year of follow-up, 1,136 biopsies and concurrent blood samples were obtained, and 56 patients (73%) experienced at least one episode of AR. All biomarkers were elevated directly after HTx and achieved steady-state after ∼ 12 weeks, both in patients with or without AR. No associations were present between the repeated measurements of NT-proBNP, TropT, or CRP and AR both early (weeks 0-12) and late (weeks 13-52) in the course after HTx (hazard ratios for weeks 13-52: 0.96 (95% confidence interval, 0.55-1.68), 0.67 (0.27-1.69), and 1.44 (0.90-2.30), respectively, per ln[unit]). Combining the three biomarkers in one model also rendered null results. CONCLUSION The temporal evolution of NT-proBNP, TropT, and CRP before AR did not predict occurrence of acute AR both in the early and late course of the first year after HTx.
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Lu W, Zheng J, Pan XD, Zhang MD, Zhu TY, Li B, Sun LZ. Diagnostic performance of cardiac magnetic resonance for the detection of acute cardiac allograft rejection: a systematic review and meta-analysis. J Thorac Dis 2015; 7:252-63. [PMID: 25922701 DOI: 10.3978/j.issn.2072-1439.2015.01.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 12/10/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Several studies have addressed the diagnostic accuracy of cardiac magnetic resonance (CMR) to assess acute cardiac allograft rejection (ACAR) compared with endomyocardial biopsy (EMB). But the methodological heterogeneity limited the clinical application of CMR. Accordingly, we have sought a comprehensive, systematic literature review and meta-analysis for the purpose. METHODS Studies prior to September 1, 2014 identified by Medline/PubMed, EMBASE and Cochrance search and citation tracking were examined by two independent reviewers. A study was included if a CMR was used as a diagnostic test for the detection of ACAR. RESULTS Of the seven articles met the inclusion criteria. Only four studies using T2 relaxation time as a CMR parameter could be pooled results, because the number of studies using other parameters was less than three. By using DerSimonian-Laird random effects model, meta-analysis demonstrated a pooled sensitivity of 90% [95% confidence interval (CI), 79% to 97%], a pooled specificity of 83% (95% CI, 78% to 88%), and a pooled diagnostic odds ratio (DOR) of 61.66 (95% CI, 18.09 to 210.10). CONCLUSIONS CMR seems to have a high sensitivity and moderate specificity in the diagnosis of ACAR. However, as a result of CMR for diagnostic ACAR should be comprehensively considered by physicians and imaging experts in the context of clinical presentations and imaging feature. Further investigations are still required to test different parameters and study condition.
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Affiliation(s)
- Wei Lu
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China ; 2 Department of Cardiology, 3 Department of Pediatric Heart Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Jun Zheng
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China ; 2 Department of Cardiology, 3 Department of Pediatric Heart Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Xu-Dong Pan
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China ; 2 Department of Cardiology, 3 Department of Pediatric Heart Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Ming-Duo Zhang
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China ; 2 Department of Cardiology, 3 Department of Pediatric Heart Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Tie-Yuan Zhu
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China ; 2 Department of Cardiology, 3 Department of Pediatric Heart Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Bin Li
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China ; 2 Department of Cardiology, 3 Department of Pediatric Heart Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Li-Zhong Sun
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China ; 2 Department of Cardiology, 3 Department of Pediatric Heart Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
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Ambrosi P, Kreitmann B, Fromonot J, Habib G, Guieu R. Plasma Ultrasensitive Cardiac Troponin During Long-Term Follow-up of Heart Transplant Recipients. J Card Fail 2015; 21:103-7. [DOI: 10.1016/j.cardfail.2014.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 08/18/2014] [Accepted: 10/27/2014] [Indexed: 12/30/2022]
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20
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Evaluation of assays for troponin I in healthy horses and horses with cardiac disease. Vet J 2015; 203:97-102. [DOI: 10.1016/j.tvjl.2014.11.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 11/25/2014] [Accepted: 11/27/2014] [Indexed: 11/24/2022]
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22
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Patel PC, Hill DA, Ayers CR, Lavingia B, Kaiser P, Dyer AK, Barnes AP, Thibodeau JT, Mishkin JD, Mammen PPA, Markham DW, Stastny P, Ring WS, de Lemos JA, Drazner MH. High-sensitivity cardiac troponin I assay to screen for acute rejection in patients with heart transplant. Circ Heart Fail 2014; 7:463-9. [PMID: 24733367 DOI: 10.1161/circheartfailure.113.000697] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A noninvasive biomarker that could accurately diagnose acute rejection (AR) in heart transplant recipients could obviate the need for surveillance endomyocardial biopsies. We assessed the performance metrics of a novel high-sensitivity cardiac troponin I (cTnI) assay for this purpose. METHODS AND RESULTS Stored serum samples were retrospectively matched to endomyocardial biopsies in 98 cardiac transplant recipients, who survived ≥3 months after transplant. AR was defined as International Society for Heart and Lung Transplantation grade 2R or higher cellular rejection, acellular rejection, or allograft dysfunction of uncertain pathogenesis, leading to treatment for presumed rejection. cTnI was measured with a high-sensitivity assay (Abbott Diagnostics, Abbott Park, IL). Cross-sectional analyses determined the association of cTnI concentrations with rejection and International Society for Heart and Lung Transplantation grade and the performance metrics of cTnI for the detection of AR. Among 98 subjects, 37% had ≥1 rejection episode. cTnI was measured in 418 serum samples, including 35 paired to a rejection episode. cTnI concentrations were significantly higher in rejection versus nonrejection samples (median, 57.1 versus 10.2 ng/L; P<0.0001) and increased in a graded manner with higher biopsy scores (P(trend)<0.0001). The c-statistic to discriminate AR was 0.82 (95% confidence interval, 0.76-0.88). Using a cut point of 15 ng/L, sensitivity was 94%, specificity 60%, positive predictive value 18%, and negative predictive value 99%. CONCLUSIONS A high-sensitivity cTnI assay seems useful to rule out AR in cardiac transplant recipients. If validated in prospective studies, a strategy of serial monitoring with a high-sensitivity cTnI assay may offer a low-cost noninvasive strategy for rejection surveillance.
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Affiliation(s)
- Parag C Patel
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Douglas A Hill
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Colby R Ayers
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Bhavna Lavingia
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Patricia Kaiser
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Adrian K Dyer
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Aliessa P Barnes
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Jennifer T Thibodeau
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Joseph D Mishkin
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Pradeep P A Mammen
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - David W Markham
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Peter Stastny
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - W Steves Ring
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - James A de Lemos
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas.
| | - Mark H Drazner
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas.
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Karimian N, Turner APF, Tiwari A. Electrochemical evaluation of troponin T imprinted polymer receptor. Biosens Bioelectron 2014; 59:160-5. [PMID: 24727601 DOI: 10.1016/j.bios.2014.03.013] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 03/01/2014] [Accepted: 03/05/2014] [Indexed: 10/25/2022]
Abstract
The selective detection and quantification of macromolecular targets is a fundamental biological mechanism in nature. Molecularly imprinted polymers (MIPs) have been identified as one of the most promising synthetic alternatives to bioreceptors. However, expanding this methodology towards selective recognition of bulky templates such as proteins appears to be extremely challenging due to problems associated with removal of the template from the polymeric network. In this study, polymer imprinted with troponin T (TnT) was assessed using electrochemical methods and the influence of various extraction methods, including conventional immersion extraction, thermal annealing and ultrasonic-assisted extraction, on the binding characteristics of the troponin-to-imprinted polymer receptor was elucidated. Cyclic voltammetric deposition of o-phenylenediamine (o-PD) film in the presence of TnT as a template was performed in acetate buffer (0.5 M, pH 5.2) on a gold substrate. Solvent extraction of the target molecule was optimised and followed by subsequent washing with water. The electrochemistry of a ferro/ferricyanide probe was used to characterise the TnT MIP receptor film. The incubation of the TnT MIP receptor-modified electrode with respect to TnT concentration resulted in a suppression of the ferro/ferricyanide redox current. The dissociation constant (KD) was calculated using a two-site model of template affinity for the TnT MIP receptor. The synthetic TnT MIP receptor had high affinity for TnT with a KD of 2.3×10(-13) M.
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Affiliation(s)
- Najmeh Karimian
- Biosensors and Bioelectronics Centre, Department of Physics, Chemistry and Biology (IFM), Linköping University, S-58183 Linköping, Sweden; Department of Chemistry, Faculty of Sciences, Ferdowsi University of Mashhad, Mashhad, Iran
| | - Anthony P F Turner
- Biosensors and Bioelectronics Centre, Department of Physics, Chemistry and Biology (IFM), Linköping University, S-58183 Linköping, Sweden
| | - Ashutosh Tiwari
- Biosensors and Bioelectronics Centre, Department of Physics, Chemistry and Biology (IFM), Linköping University, S-58183 Linköping, Sweden.
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Special topics: cardiac markers in myocarditis: cardiac transplant rejection and conditions other than acute coronary syndrome. Clin Lab Med 2014; 34:129-35, vii. [PMID: 24507792 DOI: 10.1016/j.cll.2013.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The utility of blood biomarkers of cardiac myocyte damage such as troponin T and I in the evaluation of acute coronary syndromes and heart failure is well established. However, some of these markers may also be elevated in other conditions, such as myocarditis, cardiac transplant rejection, and several other conditions. Recognizing this phenomenon is essential to avoid misdiagnosis of acute coronary syndromes. Furthermore, identifying an elevated troponin level in patients without acute coronary syndrome or heart failure may often have diagnostic or prognostic significance.
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25
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Karimian N, Vagin M, Zavar MHA, Chamsaz M, Turner AP, Tiwari A. An ultrasensitive molecularly-imprinted human cardiac troponin sensor. Biosens Bioelectron 2013; 50:492-8. [DOI: 10.1016/j.bios.2013.07.013] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 07/06/2013] [Indexed: 10/26/2022]
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Do established biomarkers such as B-type natriuretic peptide and troponin predict rejection? Curr Opin Organ Transplant 2013; 18:581-8. [DOI: 10.1097/mot.0b013e328364fe23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Erbel C, Taskin R, Doesch A, Dengler TJ, Wangler S, Akhavanpoor M, Ruhparwar A, Giannitsis E, Katus HA, Gleissner CA. High-sensitive Troponin T measurements early after heart transplantation predict short- and long-term survival. Transpl Int 2012; 26:267-72. [DOI: 10.1111/tri.12024] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 05/15/2012] [Accepted: 10/30/2012] [Indexed: 11/29/2022]
Affiliation(s)
| | - Rukiye Taskin
- Department of Cardiology; University of Heidelberg; Germany
| | - Andreas Doesch
- Department of Cardiology; University of Heidelberg; Germany
| | | | | | | | - Arjang Ruhparwar
- Department of Cardiac Surgery; University of Heidelberg; Germany
| | | | - Hugo A. Katus
- Department of Cardiology; University of Heidelberg; Germany
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ACCF 2012 expert consensus document on practical clinical considerations in the interpretation of troponin elevations: a report of the American College of Cardiology Foundation task force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2012; 60:2427-63. [PMID: 23154053 DOI: 10.1016/j.jacc.2012.08.969] [Citation(s) in RCA: 263] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Tutarel O, Golla P, Beutel G, Bauersachs J, David S, Schmidt BMW, Lichtinghagen R, Kielstein JT. Therapeutic plasma exchange decreases levels of routinely used cardiac and inflammatory biomarkers. PLoS One 2012; 7:e38573. [PMID: 22685586 PMCID: PMC3369845 DOI: 10.1371/journal.pone.0038573] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 05/07/2012] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Therapeutic plasma exchange (TPE) plays a key role in the management of various diseases, from thrombotic thrombocytopenic purpura and Goodpasture's syndrome to cardiac allograft rejection. In many of these disease states cardiac and inflammatory involvement is common and biomarkers are routinely used for diagnosis or assessment of therapeutic success. The effect of TPE on biomarkers used in the clinical routine has not been investigated. METHODS TPE was initiated for established clinical conditions in 21 patients. Troponin T, NT-proBNP, C-reactive protein, procalcitonin and routine chemistry were drawn before and after TPE, as well as before and after the 2(nd) TPE. The total amount of these markers in the waste bag was also analyzed. RESULTS In 21 patients 42 TPEs were performed. The procedure reduced plasma levels of the examined biomarkers: 23% for NT-proBNP (pre vs. post: 4637±10234 ng/l to 3565±8295 ng/l, p<0.001), 64% for CRP (21.9±47.0 mg/l vs. 7.8±15.8 mg/l, p<0.001) and 31% for procalcitonin (0.39±1.1 µg/l vs. 0.27±0.72 µg/l, p=0.004). TPE also tended to reduce plasma levels of troponin T by about 14% (60.7±175.5 ng/l vs. 52.2±141.3 ng/l), however this difference was not statistical significant (p=0.95). There was a significant correlation between the difference of pre TPE levels to post TPE levels of all examined biomarkers and the total amount of the removed biomarker in the collected removed plasma. CONCLUSIONS TPE significantly reduces plasma levels of inflammatory and cardiac biomarkers. Therefore, post TPE levels of cardiac and inflammatory biomarkers should be viewed with caution.
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Affiliation(s)
- Oktay Tutarel
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Paulina Golla
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Gernot Beutel
- Department of Hematology, Hemostaseology, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Sascha David
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | | | - Ralf Lichtinghagen
- Department of Clinical Chemistry, Hannover Medical School, Hannover, Germany
| | - Jan T. Kielstein
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
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[Usefulness of high sensitivity troponin T assay in detecting acute allograft rejection after heart transplantation]. Rev Esp Cardiol 2011; 64:1109-13. [PMID: 21924812 DOI: 10.1016/j.recesp.2011.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 06/19/2011] [Indexed: 11/22/2022]
Abstract
INTRODUCTION AND OBJECTIVES Detection of acute allograft rejection in heart transplant recipients by noninvasive methods is a challenge in the management of these patients. In this study, the usefulness of a new highly sensitive method for the measurement of troponin T is evaluated. METHODS We designed a case-crossover study, in which each patient served as his or her own control, by selecting samples from treated acute rejection episodes (29 cases) and samples obtained immediately before and/or after rejection (38 controls). The highly sensitive troponin T was measured by a new pre-commercial test (Elecsys Troponin T HS). RESULTS In all samples, highly sensitive troponin T was detectable, with a median of 0.068 ng/L (IQR, 0.030-0.300 ng/L). The levels correlated with right atrial pressure (r=0.37; P=.002), N-terminal pro-brain natriuretic peptide concentration (r=0.67; P<.001), and time since transplantation (r=-0.81; P<.001). The highly sensitive troponin T concentrations were higher in patients with rejection (0.155 ng/mL vs 0.047 ng/mL; P=.006). In the receiver operating characteristic analysis, the area under the curve was 0.67 (95% confidence interval, 0.53-0.77) and the best cutoff was 0.035 ng/mL, which was associated with rejection (odds ratio=3.7; 95% confidence interval, 1.2-11.9; P=.02). By restricting the analysis to the first 2 months, the area under the curve increased to 0.86 (95% confidence interval 0.66-0.97), with an optimal cutoff of 1.10 ng/mL (S=58% [28%-85%]; E=100% [74%-100%]). CONCLUSIONS Troponin T was detectable in all samples when a new highly sensitive assay was used, and at higher concentrations in the presence of acute rejection; however, the usefulness of this test in patient management is limited to support for clinical or histological suspicion of rejection, especially in the early post-transplant period.
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Flögel U, Su S, Kreideweiss I, Ding Z, Galbarz L, Fu J, Jacoby C, Witzke O, Schrader J. Noninvasive detection of graft rejection by in vivo (19) F MRI in the early stage. Am J Transplant 2011; 11:235-44. [PMID: 21214858 DOI: 10.1111/j.1600-6143.2010.03372.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Diagnosis of transplant rejection requires tissue biopsy and entails risks. Here, we describe a new (19) F MRI approach for noninvasive visualization of organ rejection via the macrophage host response. For this, we employed biochemically inert emulsified perfluorocarbons (PFCs), known to be preferentially phagocytized by monocytes and macrophages. Isografts from C57BL/6 or allografts from C57B10.A mice were heterotopically transplanted into C57BL/6 recipients. PFCs were applied intravenously followed by (1) H/(19) F MRI at 9.4 T 24 h after injection. (1) H images showed a similar position and anatomy of the graft in the abdomen for both cases. However, corresponding (19) F signals were only observed in allogenic tissue. (1) H/(19) F MRI enabled us to detect the initial immune response not later than 3 days after surgery, when conventional parameters did not reveal any signs of rejection. In allografts, the observed (19) F signal strongly increased with time and correlated with the extent of rejection. In separate experiments, rapamycin was used to demonstrate the ability of (19) F MRI to monitor immunosuppressive therapy. Thus, PFCs can serve as positive contrast agent for the early detection of transplant rejection by (19) F MRI with high spatial resolution and an excellent degree of specificity due to lack of any (19) F background.
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Affiliation(s)
- U Flögel
- Cardiovascular Physiology, Heinrich Heine University Düsseldorf, Germany.
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Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S, Fedson S, Fisher P, Gonzales-Stawinski G, Martinelli L, McGiffin D, Smith J, Taylor D, Meiser B, Webber S, Baran D, Carboni M, Dengler T, Feldman D, Frigerio M, Kfoury A, Kim D, Kobashigawa J, Shullo M, Stehlik J, Teuteberg J, Uber P, Zuckermann A, Hunt S, Burch M, Bhat G, Canter C, Chinnock R, Crespo-Leiro M, Delgado R, Dobbels F, Grady K, Kao W, Lamour J, Parry G, Patel J, Pini D, Towbin J, Wolfel G, Delgado D, Eisen H, Goldberg L, Hosenpud J, Johnson M, Keogh A, Lewis C, O'Connell J, Rogers J, Ross H, Russell S, Vanhaecke J, Russell S, Vanhaecke J. The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. J Heart Lung Transplant 2010; 29:914-56. [PMID: 20643330 DOI: 10.1016/j.healun.2010.05.034] [Citation(s) in RCA: 1147] [Impact Index Per Article: 81.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Accepted: 05/31/2010] [Indexed: 12/26/2022] Open
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Abstract
Cardiac troponin levels are routinely measured for diagnosing acute myocardial infarction. Cardiac troponin measurements also provide information concerning prognosis and the effect of early intervention in patients with acute coronary syndromes. The recent development of highly sensitive cardiac troponin assays permits detection of very low circulating levels. Use of sensitive troponin assays improves overall diagnostic accuracy in patients with suspected acute coronary syndromes, and these assays provide strong prognostic information in stable coronary artery disease and chronic heart failure. However, increased sensitivity comes with a cost of decreased specificity, and serial testing, as well as clinical context and judgment, is likely to become increasingly important in the interpretation of troponin assay results.
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Affiliation(s)
- T Omland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
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34
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Abstract
Cardiac troponin is the biomarker of choice for the diagnosis of acute myocardial infarction. Recent consensus recommendations have adopted a concentration of troponin above the 99th percentile of a healthy population to diagnose myocardial infarction. Until recently, there was no assay capable of achieving recommended precision; however, with the development of "highly sensitive" troponin assays, it is now possible to accurately measure troponin concentrations at and below the current 99th percentile of a healthy population. These assays have enormous potential in not only identifying more patients with acute myocardial infarction, and providing superior risk prediction in those so afflicted, in addition highly sensitive troponins assays may be useful for long-term risk assessment of the patient with coronary disease. In this article, we will review the clinical applications, novel concepts, challenges, and limitations of using highly sensitive troponins assays.
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35
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Frick M, Antretter H, Pachinger O, Pölzl G. Biomarker zur Diagnose der zellulären Abstoßung nach Herztransplantation. Herz 2010; 35:11-6. [DOI: 10.1007/s00059-010-3309-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kelley WE, Januzzi JL, Christenson RH. Increases of cardiac troponin in conditions other than acute coronary syndrome and heart failure. Clin Chem 2009; 55:2098-112. [PMID: 19815610 DOI: 10.1373/clinchem.2009.130799] [Citation(s) in RCA: 147] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although cardiac troponin (cTn) is a cornerstone marker in the assessment and management of patients with acute coronary syndrome (ACS) and heart failure (HF), cTn is not diagnostically specific for any single myocardial disease process. This narrative review discusses increases in cTn that result from acute and chronic diseases, iatrogenic causes, and myocardial injury other than ACS and HF. CONTENT Increased cTn concentrations have been reported in cardiac, vascular, and respiratory disease and in association with infectious processes. In cases involving acute aortic dissection, cerebrovascular accident, treatment in an intensive care unit, and upper gastrointestinal bleeding, increased cTn predicts a longer time to diagnosis and treatment, increased length of hospital stay, and increased mortality. cTn increases are diagnostically and prognostically useful in patients with cardiac inflammatory diseases and in patients with respiratory disease; in respiratory disease cTn can help identify patients who would benefit from aggressive management. In chronic renal failure patients the diagnostic sensitivity of cTn for ACS is decreased, but cTn is prognostic for the development of cardiovascular disease. cTn also provides useful information when increases are attributable to various iatrogenic causes and blunt chest trauma. SUMMARY Information on the diagnostic and prognostic uses of cTn in conditions other than ACS and heart failure is accumulating. Although increased cTn in settings other than ACS or heart failure is frequently considered a clinical confounder, the astute physician must be able to interpret cTn as a dynamic marker of myocardial damage, using clinical acumen to determine the source and significance of any reported cTn increase.
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Affiliation(s)
- Walter E Kelley
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA.
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37
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Limited utility of endomyocardial biopsy in the first year after heart transplantation. Transplantation 2008; 85:969-74. [PMID: 18408576 DOI: 10.1097/tp.0b013e318168d571] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surveillance endomyocardial biopsies (EMBs) are used for the early diagnosis of acute cardiac allograft rejection. Protocols became standardized in an earlier era and their utility with contemporary immunosuppression has not been investigated. METHODS We studied 258 patients after orthotopic heart transplantation comparing 135 patients immunosuppressed by mycophenolate mofetil (MMF) with 123 patients treated by azathioprine (AZA); both with cyclosporine and corticosteroids after induction therapy with rabbit antithymocyte globulin. Fifteen EMBs were scheduled in the first year. Additional EMBs were performed for suspected rejection, after treatment, or for inadequate samples. The MMF group had 1875 EMBs vs. 1854 in the AZA group. RESULTS The yield of International Society for Heart and Lung Transplantation (ISHLT) grade> or =3A biopsy-proven acute rejection (BPAR) was 1.87% per biopsy (35 of 1875) with MMF vs. 3.13% (58 of 1854) with AZA P=0.024. The number of clinically silent BPAR ISHLT grade > or =3A (the true yield of surveillance EMBs) was 1.39% (26 of 1875) of biopsies MMF vs. 2.1% (39 of 1854) AZA, P=0.48. There were five serious complications requiring intervention or causing long-term sequelae; 0.13% (5 of 3729) per biopsy and 1.94% (5 of 258) per patient. The incidence of all definite and potential complications was 1.42% (53 of 3729) per biopsy and 20.5% (53 of 258) per patient. There was no biopsy-related mortality. CONCLUSION The yield of BPAR was low in the AZA group and very low in the MMF group. The incidence of complications was also low, but repeated biopsies led to a higher rate per patient. Routine surveillance EMBs and the frequency of such biopsies should be reevaluated in the light of their low yield with current immunosuppression.
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DE GENNARO LUISA, BRUNETTI NATALEDANIELE, CUCULO ANDREA, PELLEGRINO PIERLUIGI, IZZO PAOLO, ROMA FRANCESCO, DI BIASE MATTEO. Increased Troponin Levels in Nonischemic Cardiac Conditions and Noncardiac Diseases. J Interv Cardiol 2008; 21:129-39. [DOI: 10.1111/j.1540-8183.2007.00336.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Bañón-Maneus E, Kahbiri E, Marín JL, Pomar-Moya JL, Ramírez J, Climent F, de la Ossa PP. Increased serum creatine kinase is a reliable marker for acute transplanted heart rejection diagnosis in rats. Transpl Int 2007; 20:184-9. [PMID: 17239027 DOI: 10.1111/j.1432-2277.2006.00410.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Different molecules have been studied as biochemical markers in heart transplantation. However, their utility is under discussion as results in human and animal models are controversial. In this work, lactate dehydrogenase (LDH), creatine kinase (CK) and cardiac troponin I (TnI) were studied as serologic markers of acute rejection after heterotopical heart transplantation in rats. In predictable rejection experiments, animals were divided into three groups: nonoperated (Lewis rats), control group (Lewis-Lewis isografts) and rejection group (Brown Norway-Lewis allografts). Nonpredictable rejection experiments were performed using nonconsanguineous Sprague-Dawley allografts. In predictable rejection experiments, LDH activity was similar between control and rejection groups. TnI values were heterogeneous in control and rejection groups. In contrast, the rejection group showed CK activity increased 4.5-fold compared with the control group. In addition to these predictable studies, we also presented novel nonpredictable experiments in which rats were divided into groups based on low and high CK activity. Histologic studies in these rats showed that none of those with low CK activity presented rejection signs, while all animals with high CK levels showed grade 2R rejection. These results suggest that CK might be an excellent marker for prediction of rejection in heart transplantation.
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Affiliation(s)
- Elisenda Bañón-Maneus
- Departament de Ciéncies Fisiològiques I, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Unitat de Bioquímica, Facultat de Medicina, Universitat de Barcelona, and Departament de Cirurgia i Especialitats Quirúrgiques, Hospital Clinic, Spain
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40
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Miller LW. Heart Transplantation: Pathogenesis, Immunosuppression, Diagnosis, and Treatment of Rejection. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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41
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Dengler TJ, Gleissner CA, Klingenberg R, Sack FU, Schnabel PA, Katus HA. Biomarkers After Heart Transplantation: Nongenomic. Heart Fail Clin 2007; 3:69-81. [DOI: 10.1016/j.hfc.2007.02.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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43
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Berroëta C, Provenchère S, Mongredien A, Lasocki S, Benessiano J, Dehoux M, Philip I. Dosage des isoformes cardiaques des troponines T ou I : intérêt en cardiologie et en anesthésie–réanimation. ACTA ACUST UNITED AC 2006; 25:1053-63. [PMID: 16019183 DOI: 10.1016/j.annfar.2005.05.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2004] [Accepted: 05/09/2005] [Indexed: 01/08/2023]
Abstract
Measurement of cardiac troponin I or T in serum (highly specific for the myocardium) have replaced classical markers, such as creatine kinase MB. Cardiac troponins are preferred markers because of their high specificity and sensitivity. This had led to modifications of the original World Health Organization criteria for acute myocardial infarction. Furthermore, the place of the troponins as superior markers of subsequent cardiac risk in acute coronary syndrome has now become firmly established, for both diagnostic and risk stratification purposes. The use of C-reactive protein and/or other inflammatory biomarkers may add independent information in this context. After non cardiac surgery, the total cardiospecificity of cardiac troponins explains why other biomarkers of necrosis should no longer be used. Recent studies suggest that any elevation of troponin in the postoperative period is indicative of increased risk of long-term cardiac complications. This prognostic value has been previously demonstrated in other clinical settings such as invasive coronary intervention (surgical myocardial revascularization and percutaneous coronary intervention) and after heart valve surgery. Increases of troponin indicate cardiac damage, whatever the mechanism (ischemic or not). Other causes of cardiac injury include: pulmonary embolism, myocarditis, pericarditis, congestive heart failure, septic shock, myocardial contusion. In most cases, elevation of troponins has been shown to be associated with a bad outcome.
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Affiliation(s)
- C Berroëta
- Département d'anesthésie-réanimation, hôpital Bichat-Claude-Bernard, Assistance publique-Hôpitaux de Paris, 48 rue Henri-Huchard, 75018 Paris, France
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44
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Affiliation(s)
- Susanne Korff
- Department of Medicine III, University of Heidelberg, Germany
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45
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Pruvot S, Galidie G, Bergmann JF, Mahé I. La troponine et les autres marqueurs de souffrance myocardique, quelle signification en médecine interne ? Rev Med Interne 2006; 27:215-26. [PMID: 16337716 DOI: 10.1016/j.revmed.2005.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2005] [Accepted: 09/28/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE Troponin is now the gold standard for the diagnosis of myocardial infarction. Aiming at improving the management of a patient suspect of an acute coronary syndrome, this article will point the interpretation of troponin dosages according to the clinical presentation and concomitant diseases. ACTUALITIES First, the interest of troponin dosage as compared with other markers of myocardial ischemia will be underlined. Then, the literature available about troponin in cardiovascular diseases but also in extracardiac diseases will be analysed. Finally, the difficulties of assay will be discussed. PERSPECTIVES The availability of a sensitive and specific marker such as troponin is definitively a progress in the management of patients with an acute coronary syndromes. But it remains a biological contribution to the global management of the patient. It is important to know the causes susceptible to increase the levels of troponin to avoid a wrong interpretation of the dosage, leading to diagnostic but also therapeutic mistakes.
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Affiliation(s)
- S Pruvot
- Service de Médecine A, Hôpital Lariboisière, Paris, France
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46
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Gilman G, Hansen WH, Hagen ME, Rosales AG, Bailey KR, McGregor CGA, Belohlavek M. An Echocardiographic Left Ventricular Wall Area Index for Functional Detection of Myocardial Injury in Hemodynamically Unloaded Hearts. Echocardiography 2006; 23:7-13. [PMID: 16412177 DOI: 10.1111/j.1540-8175.2005.00161.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Functional assessment of the left ventricle is affected by loading conditions. Detection of rejection-mediated myocardial injury in a heterotopic heart transplant model is a challenge for the echocardiographer because the heart is in an unloaded state. We examined the relationship of a novel left ventricular (LV) wall area index (LVWAI) and serum cardiac troponin T (cTnT) levels. The LVWAI, based on prior methods of determining LV mass, was defined as the difference between epicardial and endocardial areas divided by the epicardial area. The biphasic morphometric response of LVWAI reflected changes in the cTnT levels and allowed echocardiographic detection of myocardial injury in hemodynamically unloaded hearts.
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Affiliation(s)
- Gregory Gilman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA
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47
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Abstract
The emergence of cardiac troponins has been an interesting step in the diagnosis of ACS. It has clearly helped us to better triage patients toward a more aggressive posture in performing early cardiac catheterization, and in some cases, early use of adjunctive Gp IIb/IIIa antagonists and percutaneous or surgical myocardial revascularization. However, with this step forward has come uncertainty and many cardiology consults regarding positive cardiac troponins in patients without ACS or myocardial infarction. In general, increased cardiac troponins imply a worse prognosis. This is clearly true of patients with ESRD and advanced heart failure. It is also true of patients with severe, noncardiac illnesses. In other situations, such as acute pericarditis and cardiac surgery, slightly elevated cardiac troponins do not seem to predict a worse prognosis, and can probably be disregarded. The elevation of cardiac troponins after successful percutaneous coronary interventions is not unexpected, and the level of cardiac troponin release seems to predict problems, but lively controversy persists. Last, monitoring cardiac troponins in cardiac transplant recipients and those receiving certain cardiotoxic chemotherapies may be of some diagnostic value, but clearly more experience and clinical research are needed.
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Affiliation(s)
- Gary S Francis
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, F25, Cleveland, Ohio 44195, USA.
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48
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Borozdenkova S, Westbrook JA, Patel V, Wait R, Bolad I, Burke MM, Bell AD, Banner NR, Dunn MJ, Rose ML. Use of Proteomics to Discover Novel Markers of Cardiac Allograft Rejection. J Proteome Res 2004; 3:282-8. [PMID: 15113105 DOI: 10.1021/pr034059r] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Endomyocardial biopsy remains the most reliable method of detecting rejection following cardiac transplantation. Despite numerous attempts to detect rejection using a blood assay, none have proved reliable enough to replace the biopsy. Here, we have investigated the hypothesis that proteomics has the potential to reveal many molecules which are upregulated in the heart during rejection, some of which may serve as novel blood markers of rejection. Initially, sequential cardiac biopsies (33 in total) from 4 patients were analysed by two-dimensional gel electrophoresis according to whether they showed rejection (n = 16) or no rejection (n = 17); over 100 proteins were found to be upregulated by between 2- and 50-fold during rejection. Of these, 13 were identified and were found to be cardiac specific or heat shock proteins. Two of these (alphaB-crystallin, tropomyosin) were measured by ELISA in the sera of 17 patients followed for 3 months after their transplants. Mean levels of alphaB-crystallin and tropomyosin were significantly higher in sera associated with biopsies showing 1A (p = 0.007) or all grades of rejection (p = 0.022) compared to no rejection. These studies demonstrate that proteomics is a powerful method that can be used to identify novel serum markers of human cardiac allograft rejection.
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Affiliation(s)
- Svetlana Borozdenkova
- National Heart and Lung Institute, Imperial College School of Medicine, Heart Science Centre, Harefield Hospital, Harefield, United Kingdom
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49
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Gleissner CA, Klingenberg R, Nottmeyer W, Zipfel S, Sack FU, Schnabel PA, Haass M, Dengler TJ. Diagnostic efficiency of rejection monitoring after heart transplantation with cardiac troponin T is improved in specific patient subgroups. Clin Transplant 2003; 17:284-91. [PMID: 12780681 DOI: 10.1034/j.1399-0012.2003.00050.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Cardiac troponin T (cTnT) is a cardio-specific myofibrillar protein known to be elevated early after heart transplantation and during cardiac allograft rejection. cTnT determination in heart allograft recipients showed elevated levels in patients with higher degrees of graft rejection (International Society for Heart and Lung Transplantation grades >/=3A-4). Subgroup analyses revealed demographic patient characteristics markedly improving the diagnostic efficiency of cTnT measurement for rejection monitoring, including male recipient gender, recipient age <60 yr, female donor gender and donor age >/= 33 yr. The clinical utility of these parameters was confirmed by longitudinal patient data and may help to select recipients most likely to benefit from cTnT rejection surveillance.
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Siaplaouras J, Thul J, Krämer U, Bauer J, Schranz D. Cardiac troponin I: a marker of acute heart rejection in infant and child heart recipients? Pediatr Transplant 2003; 7:43-5. [PMID: 12581327 DOI: 10.1034/j.1399-3046.2003.02049.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Acute rejection of the donor heart is a major cause of mortality in infant heart transplant recipients. The early diagnosis of acute cardiac rejection (ACR) is crucial. Non-invasive methods have shown poor sensitivity in detecting rejection when compared to endomyocardial biopsies (EMB). We assessed troponin I as a new marker to diagnose cardiac rejection. Serum cardiac troponin I (cTNI) levels were retrospectively analysed in 25 heart transplant patients (ages, 2 wk to 13 yr; mean age, 3 months) presenting 36 acute rejections. In early post-operative rejection and initially elevated cTNI levels, rejection was associated with a second increase of serum cTNI concentrations in 21% of the patients (p = 0.15). If cTNI levels were in normal range before ACR an elevation was monitored in 59% of the rejection periods (p < 0.05). In 25% of the cases (n = 9) cTNI levels remained in normal range during the rejection episode (<0.6 ng/mL), in 22% (n = 8) cTNI levels did not exceed pathological values from 0.6 to 1.5 ng/mL and in 53% (n = 19) the measured levels went beyond 1.5 ng/mL. Maximum concentrations of cTNI were measured mostly 12 d from the moment rejection was suspected (day 1) in patients (median day 3). However, cTNI levels were elevated for 2-43 d after ACR was diagnosed (median 10 d). Twenty per cent of the patients with grade 3 rejection (ISHLT) and 75% of the patients with grade 4 rejection had a corresponding elevated cTNI level (p = 0.013). No false-positive elevations of cTNI were documented. The present data demonstrate that cTNI is a not a sensitive but a specific marker of ACR in children.
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Affiliation(s)
- J Siaplaouras
- Kinderklinik der Justus-Liebig-Universität Giessen, Kinderherzzentrum, Giessen, Germany
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