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Pérez-Carrillo L, Sánchez-Lázaro I, Triviño JC, Feijóo-Bandín S, Lago F, González-Juanatey JR, Martínez-Dolz L, Portolés M, Tarazón E, Roselló-Lletí E. Combining Serum miR-144-3p and miR-652-3p as Potential Biomarkers for the Early Diagnosis and Stratification of Acute Cellular Rejection in Heart Transplantation Patients. Transplantation 2023; 107:2064-2072. [PMID: 37606906 PMCID: PMC10442084 DOI: 10.1097/tp.0000000000004622] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/27/2023] [Accepted: 02/13/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND There is a dire need for specific, noninvasive biomarkers that can accurately detect cardiac acute cellular rejection (ACR) early. Previously, we described miR-144-3p as an excellent candidate for detecting grade ≥2R ACR. Now, we investigated the combination of miR-144-3p with miR-652-3p, other differentially expressed serum miRNA we previously described, to improve diagnostic accuracy mainly in mild rejection to avoid reaching severe stages. METHODS We selected miR-652-3p from a preliminary RNA-seq study to be validated by reverse transcription-quantitative polymerase chain reaction on 212 consecutive serum samples from transplantation recipients undergoing routine endomyocardial biopsies to subsequently combine them with miR-144-3p results and investigate their diagnostic capability. RESULTS We confirmed the miR-652-3p overexpression (P < 0.0001) and its capability to discriminate between patients with and without ACR of any grade (P < 0.0001). The combined serum levels of miR-144-3p and miR-652-3p were significantly higher in patients with rejection regardless of posttransplantation time (P < 0.0001). This combination resulted in a diagnostic efficacy for 1R (area under the curve = 0.794) and ≥2R (area under the curve = 0.892; P < 0.0001) that was superior to each biomarker alone. Furthermore, it was a strong independent predictor of ACR for 1R (odds ratio of 10.950; P < 0.0001) and ≥2R (odds ratio of 14.289; P < 0.01). CONCLUSIONS We demonstrated that an appropriate combination of blood-based biomarkers could exhibit greater efficiency for cardiac rejection diagnosis. The combined detection of abnormal expression of miR-144-3p and miR-652-3p in the serum of ACR patients can improve the diagnostic sensitivity of rejection at an early stage and contribute to increasing the diagnostic accuracy, mainly in the lower rejection grades.
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Affiliation(s)
- Lorena Pérez-Carrillo
- Clinical and Translational Research in Cardiology Unit, Health Research Institute Hospital La Fe (IIS La Fe), Valencia, Spain
| | - Ignacio Sánchez-Lázaro
- Clinical and Translational Research in Cardiology Unit, Health Research Institute Hospital La Fe (IIS La Fe), Valencia, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain
- Heart Failure and Transplantation Unit, Cardiology Department, University and Polytechnic La Fe Hospital, Valencia, Spain
| | | | - Sandra Feijóo-Bandín
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain
- Cellular and Molecular Cardiology Research Unit, Department of Cardiology and Institute of Biomedical Research, University Clinical Hospital, Santiago de Compostela, Spain
| | - Francisca Lago
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain
- Cellular and Molecular Cardiology Research Unit, Department of Cardiology and Institute of Biomedical Research, University Clinical Hospital, Santiago de Compostela, Spain
| | - José Ramón González-Juanatey
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain
- Cellular and Molecular Cardiology Research Unit, Department of Cardiology and Institute of Biomedical Research, University Clinical Hospital, Santiago de Compostela, Spain
| | - Luis Martínez-Dolz
- Clinical and Translational Research in Cardiology Unit, Health Research Institute Hospital La Fe (IIS La Fe), Valencia, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain
- Heart Failure and Transplantation Unit, Cardiology Department, University and Polytechnic La Fe Hospital, Valencia, Spain
| | - Manuel Portolés
- Clinical and Translational Research in Cardiology Unit, Health Research Institute Hospital La Fe (IIS La Fe), Valencia, Spain
| | - Estefanía Tarazón
- Clinical and Translational Research in Cardiology Unit, Health Research Institute Hospital La Fe (IIS La Fe), Valencia, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain
| | - Esther Roselló-Lletí
- Clinical and Translational Research in Cardiology Unit, Health Research Institute Hospital La Fe (IIS La Fe), Valencia, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain
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2
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Mohiuddin MM, Singh AK, Goerlich CE. Preclinical rationale and current pathways to support the first human clinical trials in cardiac xenotransplantation. Hum Immunol 2023; 84:34-42. [PMID: 35851182 PMCID: PMC10154071 DOI: 10.1016/j.humimm.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/29/2022] [Accepted: 07/07/2022] [Indexed: 01/05/2023]
Abstract
Recent initiation of the first FDA-approved cardiac xenotransplantation suggests xenotransplantation could soon become a therapeutic option for patients unable to undergo allotransplantation. Until xenotransplantation is widely applied in clinical practice, consideration of benefit versus risk and approaches to management of clinical xenografts will based at least in part on observations made in experimental xenotransplantation in non-human primates. Indeed, the decision to proceed with clinical trials reflects significant progress in last few years in experimental solid organ and cellular xenotransplantation. Our laboratory at the NIH and now at University of Maryland contributed to this progress, with heterotopic cardiac xenografts surviving more than two years and life-supporting cardiac xenografts survival up to 9 months. Here we describe our contributions to the understanding of the mechanism of cardiac xenograft rejection and development of methods to overcome past hurdles, and finally we share our opinion on the remaining barriers to clinical translation. We also discuss how the first in human xenotransplants might be performed, recipients managed, and graft function monitored.
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Chapa JJ, Ilonze OJ, Guglin ME, Rao RA. Heart transplantation in systemic lupus erythematosus: A case report and meta-analysis. Heart Lung 2022; 52:174-181. [DOI: 10.1016/j.hrtlng.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 12/28/2021] [Accepted: 01/03/2022] [Indexed: 01/20/2023]
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Pérez-Carrillo L, Sánchez-Lázaro I, Triviño JC, Feijóo-Bandín S, Lago F, González-Juanatey JR, Martínez-Dolz L, Portolés M, Tarazón E, Roselló-Lletí E. Diagnostic value of serum miR-144-3p for the detection of acute cellular rejection in heart transplant patients. J Heart Lung Transplant 2021; 41:137-147. [PMID: 34895840 DOI: 10.1016/j.healun.2021.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/22/2021] [Accepted: 10/03/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The development of noninvasive approaches for the early diagnosis of acute cellular rejection (ACR), an important complication of cardiac transplantation, is of great importance in clinical practice. We conducted a nontargeted transcriptomic study focused on identifying serum miRNAs to evaluate their diagnostic accuracy for detecting rejection episodes. METHODS We included consecutive serum samples from transplant recipients undergoing routine endomyocardial biopsies. In the discovery phase (n = 40), an RNA sequencing analysis (Illumina HiSeq 2500 sequencer) was performed. We focused on the validation of miR-144-3p in a larger patient cohort (n = 212), selected based on the criteria of higher accuracy for ACR detection. ACR was assessed according to the International Society for Heart and Lung Transplantation. RESULTS In the discovery phase, 26 altered miRNAs were identified as potential markers for detecting ACR. miR-144-3p showed the best results, it was the only molecule with an AUC greater than 0.95 to detect Grade ≥2R ACR and it showed significant differences in its levels when we compared Grade 1R ACR with the nonrejection group. In the validation phase, we confirmed this finding, and it had an excellent diagnostic capacity for clinically relevant rejection (Grade ≥2R AUC = 0.801, p < 0.0001), detecting mild rejection (Grade 1R AUC = 0.631, p < 0.01) and was an independent predictor for the presence of ACR (odds ratio of 14.538, p < 0.01). CONCLUSIONS ACR is associated with the differential expression of specific serum miRNAs that correlate with the severity of the episode. Circulating miR-144-3p is a candidate noninvasive ACR biomarker that could contribute to improving the surveillance of cardiac transplanted patients.
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Affiliation(s)
- Lorena Pérez-Carrillo
- Myocardial Dysfunction and Cardiac Transplantation Unit, Health Research Institute Hospital La Fe (IIS La Fe), Valencia, CIBERCV, Madrid, Spain
| | - Ignacio Sánchez-Lázaro
- Myocardial Dysfunction and Cardiac Transplantation Unit, Health Research Institute Hospital La Fe (IIS La Fe), Valencia, CIBERCV, Madrid, Spain; Heart Failure and Transplantation Unit, Cardiology Department, University and Polytechnic La Fe Hospital, Valencia, Spain
| | | | - Sandra Feijóo-Bandín
- Cellular and Molecular Cardiology Research Unit, Department of Cardiology and Institute of Biomedical Research, University Clinical Hospital, Santiago de Compostela, Spain; and CIBERCV, Madrid, Spain
| | - Francisca Lago
- Cellular and Molecular Cardiology Research Unit, Department of Cardiology and Institute of Biomedical Research, University Clinical Hospital, Santiago de Compostela, Spain; and CIBERCV, Madrid, Spain
| | - José Ramón González-Juanatey
- Cellular and Molecular Cardiology Research Unit, Department of Cardiology and Institute of Biomedical Research, University Clinical Hospital, Santiago de Compostela, Spain; and CIBERCV, Madrid, Spain
| | - Luis Martínez-Dolz
- Myocardial Dysfunction and Cardiac Transplantation Unit, Health Research Institute Hospital La Fe (IIS La Fe), Valencia, CIBERCV, Madrid, Spain; Heart Failure and Transplantation Unit, Cardiology Department, University and Polytechnic La Fe Hospital, Valencia, Spain
| | - Manuel Portolés
- Myocardial Dysfunction and Cardiac Transplantation Unit, Health Research Institute Hospital La Fe (IIS La Fe), Valencia, CIBERCV, Madrid, Spain
| | - Estefanía Tarazón
- Myocardial Dysfunction and Cardiac Transplantation Unit, Health Research Institute Hospital La Fe (IIS La Fe), Valencia, CIBERCV, Madrid, Spain
| | - Esther Roselló-Lletí
- Myocardial Dysfunction and Cardiac Transplantation Unit, Health Research Institute Hospital La Fe (IIS La Fe), Valencia, CIBERCV, Madrid, Spain.
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Scheiber D, Zweck E, Albermann S, Jelenik T, Spieker M, Bönner F, Horn P, Schultheiss HP, Aleshcheva G, Escher F, Boeken U, Akhyari P, Roden M, Kelm M, Szendroedi J, Westenfeld R. Human myocardial mitochondrial oxidative capacity is impaired in mild acute heart transplant rejection. ESC Heart Fail 2021; 8:4674-4684. [PMID: 34490749 PMCID: PMC8712779 DOI: 10.1002/ehf2.13607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/19/2021] [Accepted: 08/24/2021] [Indexed: 12/28/2022] Open
Abstract
Aims Acute cellular rejection (ACR) following heart transplantation (HTX) is associated with long‐term graft loss and increased mortality. Disturbed mitochondrial bioenergetics have been identified as pathophysiological drivers in heart failure, but their role in ACR remains unclear. We aimed to prove functional disturbances of myocardial bioenergetics in human heart transplant recipients with mild ACR by assessing myocardial mitochondrial respiration using high‐resolution respirometry, digital image analysis of myocardial inflammatory cell infiltration, and clinical assessment of HTX patients. We hypothesized that (i) mild ACR is associated with impaired myocardial mitochondrial respiration and (ii) myocardial inflammation, systemic oxidative stress, and myocardial oedema relate to impaired mitochondrial respiration and myocardial dysfunction. Methods and results We classified 35 HTX recipients undergoing endomyocardial biopsy according International Society for Heart and Lung Transplantation criteria to have no (0R) or mild (1R) ACR. Additionally, we quantified immune cell infiltration by immunohistochemistry and digital image analysis. We analysed mitochondrial substrate utilization in myocardial fibres by high‐resolution respirometry and performed cardiovascular magnetic resonance (CMR). ACR (1R) was diagnosed in 12 patients (34%), while the remaining 23 patients revealed no signs of ACR (0R). Underlying cardiomyopathies (dilated cardiomyopathy 50% vs. 65%; P = 0.77), comorbidities (type 2 diabetes mellitus: 50% vs. 35%, P = 0.57; chronic kidney disease stage 5: 8% vs. 9%, P > 0.99; arterial hypertension: 59% vs. 30%, P = 0.35), medications (tacrolimus: 100% vs. 91%, P = 0.54; mycophenolate mofetil: 92% vs. 91%, P > 0.99; prednisolone: 92% vs. 96%, P > 0.99) and time post‐transplantation (21.5 ± 26.0 months vs. 29.4 ± 26.4 months, P = 0.40) were similar between groups. Mitochondrial respiration was reduced by 40% in ACR (1R) compared with ACR (0R) (77.8 ± 23.0 vs. 128.0 ± 33.0; P < 0.0001). Quantitative assessment of myocardial CD3+‐lymphocyte infiltration identified ACR (1R) with a cut‐off of >14 CD3+‐lymphocytes/mm2 (100% sensitivity, 82% specificity; P < 0.0001). Myocardial CD3+ infiltration (r = −0.41, P < 0.05), systemic oxidative stress (thiobarbituric acid reactive substances; r = −0.42, P < 0.01) and myocardial oedema depicted by global CMR derived T2 time (r = −0.62, P < 0.01) correlated with lower oxidative capacity and overt cardiac dysfunction (global longitudinal strain; r = −0.63, P < 0.01). Conclusions Mild ACR with inflammatory cell infiltration associates with impaired mitochondrial bioenergetics in cardiomyocytes. Our findings may help to identify novel checkpoints in cardiac immune metabolism as potential therapeutic targets in post‐transplant care.
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Affiliation(s)
- Daniel Scheiber
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Moorenstraße 5, Düsseldorf, 40225, Germany.,Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University, Düsseldorf, Germany.,German Center for Diabetes Research (DZD e.V.), Partner Düsseldorf, München-Neuherberg, Germany
| | - Elric Zweck
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Moorenstraße 5, Düsseldorf, 40225, Germany.,Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University, Düsseldorf, Germany.,German Center for Diabetes Research (DZD e.V.), Partner Düsseldorf, München-Neuherberg, Germany
| | - Sophie Albermann
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Moorenstraße 5, Düsseldorf, 40225, Germany.,Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University, Düsseldorf, Germany.,German Center for Diabetes Research (DZD e.V.), Partner Düsseldorf, München-Neuherberg, Germany
| | - Tomas Jelenik
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University, Düsseldorf, Germany.,German Center for Diabetes Research (DZD e.V.), Partner Düsseldorf, München-Neuherberg, Germany
| | - Maximilian Spieker
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Moorenstraße 5, Düsseldorf, 40225, Germany
| | - Florian Bönner
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Moorenstraße 5, Düsseldorf, 40225, Germany
| | - Patrick Horn
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Moorenstraße 5, Düsseldorf, 40225, Germany
| | | | - Ganna Aleshcheva
- Institute for Cardiac Diagnostics and Therapy (IKDT), Berlin, Germany
| | - Felicitas Escher
- Institute for Cardiac Diagnostics and Therapy (IKDT), Berlin, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich-Heine University, Düsseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Heinrich-Heine University, Düsseldorf, Germany
| | - Michael Roden
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University, Düsseldorf, Germany.,German Center for Diabetes Research (DZD e.V.), Partner Düsseldorf, München-Neuherberg, Germany.,Cardiovascular Research Institute Düsseldorf, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany.,Division of Endocrinology and Diabetology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Moorenstraße 5, Düsseldorf, 40225, Germany.,Cardiovascular Research Institute Düsseldorf, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Julia Szendroedi
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University, Düsseldorf, Germany.,German Center for Diabetes Research (DZD e.V.), Partner Düsseldorf, München-Neuherberg, Germany.,Cardiovascular Research Institute Düsseldorf, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany.,Division of Endocrinology and Diabetology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany.,Department of Internal Medicine I and Clinical Chemistry, University Hospital Heidelberg, Heidelberg, Germany.,Institute for Diabetes and Cancer (IDC) & Joint Heidelberg-IDC Translational Diabetes Program, Helmholtz Center Munich, Neuherberg, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Moorenstraße 5, Düsseldorf, 40225, Germany
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Han D, Miller RJH, Otaki Y, Gransar H, Kransdorf E, Hamilton M, Kittelson M, Patel J, Kobashigawa JA, Thomson L, Berman D, Tamarappoo B. Diagnostic Accuracy of Cardiovascular Magnetic Resonance for Cardiac Transplant Rejection: A Meta-analysis. JACC Cardiovasc Imaging 2021; 14:2337-2349. [PMID: 34274269 DOI: 10.1016/j.jcmg.2021.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 05/10/2021] [Accepted: 05/14/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aim of this meta-analysis was to assess the diagnostic performance of various CMR imaging parameters for evaluating acute cardiac transplant rejection. BACKGROUND Endomyocardial biopsy is the current gold standard for detection of acute cardiac transplant rejection. Cardiac magnetic resonance (CMR) is uniquely capable of myocardial tissue characterization and may be useful as a noninvasive alternative for the diagnosis of graft rejection. METHODS PubMed and Web of Science were searched for relevant publications reporting on the use of CMR myocardial tissue characterization for detection of acute cardiac transplant rejection with endomyocardial biopsy as the reference standard. Pooled sensitivity, specificity, and hierarchical modeling-based summary receiver-operating characteristic curves were calculated. RESULTS Of 478 papers, 10 studies comprising 564 patients were included. The sensitivity and specificity for the detection of acute cardiac transplant rejection were 84.6 (95% CI: 65.6-94.0) and 70.1 (95% CI: 54.2-82.2) for T1, 86.5 (95% CI: 72.1-94.1) and 85.9 (95% CI: 65.2-94.6) for T2, 91.3 (95% CI: 63.9-98.4) and 67.6 (95% CI: 56.1-77.4) for extracellular volume fraction (ECV), and 50.1 (95% CI: 31.2-68.9) and 60.2 (95% CI: 36.7-79.7) for late gadolinium enhancement (LGE). The areas under the hierarchical modeling-based summary receiver-operating characteristic curve were 0.84 (95% CI: 0.81-0.87) for T1, 0.92 (95% CI: 0.89-94) for T2, 0.78 (95% CI: 0.74-0.81) for ECV, and 0.56 (95% CI: 0.51-0.60) for LGE. T2 values demonstrated the highest diagnostic accuracy, followed by native T1, ECV, and LGE (all P values < 0.001 for T1, ECV, and LGE vs T2). CONCLUSIONS T2 mapping demonstrated higher diagnostic accuracy than other CMR techniques. Native T1 and ECV provide high diagnostic use but lower diagnostic accuracy compared with T2, which was related primarily to lower specificity. LGE showed poor diagnostic performance for detection of rejection.
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Affiliation(s)
- Donghee Han
- Department of Imaging, Mark Taper Imaging Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Robert J H Miller
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Yuka Otaki
- Department of Imaging, Mark Taper Imaging Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Heidi Gransar
- Department of Imaging, Mark Taper Imaging Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Evan Kransdorf
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michelle Hamilton
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michele Kittelson
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Louise Thomson
- Department of Imaging, Mark Taper Imaging Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Daniel Berman
- Department of Imaging, Mark Taper Imaging Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Balaji Tamarappoo
- Department of Imaging, Mark Taper Imaging Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.
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Abstract
PURPOSE OF REVIEW Acute allograft rejection is a common cause of morbidity and mortality in heart and lung transplantation. Unfortunately, the current monitoring gold standard-biopsy plus histopathology-has several limitations. Plasma donor-derived cell-free DNA (dd-cfDNA) has emerged as a potentially valuable biomarker for rejection that addresses some of the limitations of biopsy. This review covers the current state of the evidence and future directions for the use of dd-cfDNA in the monitoring of acute rejection. RECENT FINDINGS The results of several observational cohort studies demonstrate that levels of dd-cfDNA increase in the setting of acute cellular rejection and antibody-mediated rejection in both heart and lung transplant recipients. dd-cfDNA demonstrates acceptable performance characteristics, but low specificity for the detection of underlying injury from rejection or infection. In particular, the high negative predictive value of the test in both heart and lung transplant patients provides the potential for its use as a screening tool for the monitoring of allograft health rather than tissue biopsy alone. SUMMARY Existing evidence shows that dd-cfDNA is a safe, convenient, and reliable method of acute rejection monitoring in heart and lung transplant recipients. Further studies are required to validate threshold values for clinical use and determine its role in the diagnosis of alternative forms of allograft injury.
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Affiliation(s)
- Michael Keller
- grid.94365.3d0000 0001 2297 5165Laborarory of Applied Precision Omics (APO) and Genomic Research Alliance for Transplantation (GRAfT), National Institute of Health, Bethesda, MD USA ,grid.94365.3d0000 0001 2297 5165Department of Critical Care Medicine, National Institute of Health, Bethesda, MD USA ,grid.411935.b0000 0001 2192 2723Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD USA
| | - Sean Agbor-Enoh
- grid.94365.3d0000 0001 2297 5165Laborarory of Applied Precision Omics (APO) and Genomic Research Alliance for Transplantation (GRAfT), National Institute of Health, Bethesda, MD USA ,grid.411935.b0000 0001 2192 2723Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD USA ,grid.279885.90000 0001 2293 4638Lasker Clinical Research Tenure Track, Laboratory of Applied Precision Omics, Division of Intramural Research, NHLBI, 10 Center Dr, Rm 7D5, Baltimore, USA
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8
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Tarazón E, Corbacho-Alonso N, Barderas MG, Gil-Cayuela C, García-Manzanares M, Feijóo-Bandín S, Lago F, González-Juanatey JR, Martínez-Dolz L, Portolés M, Roselló-Lletí E. Plasma CD5L and non-invasive diagnosis of acute heart rejection. J Heart Lung Transplant 2019; 39:257-266. [PMID: 31883820 DOI: 10.1016/j.healun.2019.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 11/12/2019] [Accepted: 11/14/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Acute rejection is one of the most important direct contributors to mortality after heart transplantation. Advances in the development of novel non-invasive approaches for the early identification of allograft rejection are necessary. We conducted a non-targeted proteome characterization focused on identifying multiple plasmatic protein differences to evaluate their diagnostic accuracy for rejection episodes. METHODS We included consecutive plasma samples from transplant recipients undergoing routine endomyocardial biopsies. A liquid chromatography-tandem mass spectrometry analysis using isobaric tags (tandem mass tag 10-plex) was performed and concentrations of CD5L were validated using a specific sandwich enzyme-linked immunosorbent assay. RESULTS A total of 17 altered proteins were identified as potential markers for detecting heart transplant rejection, most involved in inflammation and immunity. CD5L, an apoptosis inhibitor expressed by macrophages, showed the best results in the proteomic analysis (n = 30). We confirm this finding in a larger patient cohort (n = 218), obtaining a great diagnostic capacity for clinically relevant rejection (≥Grade 2R: area under the curve = 0.892, p < 0.0001) and preserving the accuracy at mild rejection (Grade 1R: area under the curve = 0.774, p < 0.0001). CD5L was a strong independent predictor, with an odds ratio of 14.74 (p < 0.0001), for the presence of rejection. CONCLUSIONS Episodes of acute cardiac allograft rejection are related to significant changes in a key inhibitor of apoptosis in macrophages, CD5L. Because of its precision to detect acute cellular rejection, even at mild grade, we propose CD5L as a potential candidate to be included in the studies of molecule combination panel assays. This finding could contribute to improving the diagnostic and preventive methods for the surveillance of cardiac transplanted patients.
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Affiliation(s)
- Estefanía Tarazón
- Myocardial Dysfunction and Cardiac Transplantation Unit, Health Research Institute Hospital La Fe, Valencia, Spain; CIBERCV, Madrid, Spain.
| | - Nerea Corbacho-Alonso
- Department of Vascular Physiopathology, Hospital Nacional de Parapléjicos, SESCAM, Toledo, Spain
| | - María G Barderas
- Department of Vascular Physiopathology, Hospital Nacional de Parapléjicos, SESCAM, Toledo, Spain
| | - Carolina Gil-Cayuela
- Myocardial Dysfunction and Cardiac Transplantation Unit, Health Research Institute Hospital La Fe, Valencia, Spain; CIBERCV, Madrid, Spain
| | - María García-Manzanares
- Medicine and Animal Surgery, CEU Cardenal Herrera University, Alfara del Patriarca, Valencia, Spain
| | - Sandra Feijóo-Bandín
- CIBERCV, Madrid, Spain; Cellular and Molecular Cardiology Research Unit, Department of Cardiology and Institute of Biomedical Research, University Clinical Hospital, Santiago de Compostela, Spain
| | - Francisca Lago
- CIBERCV, Madrid, Spain; Cellular and Molecular Cardiology Research Unit, Department of Cardiology and Institute of Biomedical Research, University Clinical Hospital, Santiago de Compostela, Spain
| | - José Ramón González-Juanatey
- CIBERCV, Madrid, Spain; Cellular and Molecular Cardiology Research Unit, Department of Cardiology and Institute of Biomedical Research, University Clinical Hospital, Santiago de Compostela, Spain
| | - Luis Martínez-Dolz
- Myocardial Dysfunction and Cardiac Transplantation Unit, Health Research Institute Hospital La Fe, Valencia, Spain; CIBERCV, Madrid, Spain; Heart Failure and Transplantation Unit, Cardiology Department, University and Polytechnic La Fe Hospital, Valencia, Spain
| | - Manuel Portolés
- Myocardial Dysfunction and Cardiac Transplantation Unit, Health Research Institute Hospital La Fe, Valencia, Spain; CIBERCV, Madrid, Spain
| | - Esther Roselló-Lletí
- Myocardial Dysfunction and Cardiac Transplantation Unit, Health Research Institute Hospital La Fe, Valencia, Spain; CIBERCV, Madrid, Spain
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9
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Hajipour MJ, Mehrani M, Abbasi SH, Amin A, Kassaian SE, Garbern JC, Caracciolo G, Zanganeh S, Chitsazan M, Aghaverdi H, Shahri SMK, Ashkarran A, Raoufi M, Bauser-Heaton H, Zhang J, Muehlschlegel JD, Moore A, Lee RT, Wu JC, Serpooshan V, Mahmoudi M. Nanoscale Technologies for Prevention and Treatment of Heart Failure: Challenges and Opportunities. Chem Rev 2019; 119:11352-11390. [PMID: 31490059 PMCID: PMC7003249 DOI: 10.1021/acs.chemrev.8b00323] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The adult myocardium has a limited regenerative capacity following heart injury, and the lost cells are primarily replaced by fibrotic scar tissue. Suboptimal efficiency of current clinical therapies to resurrect the infarcted heart results in injured heart enlargement and remodeling to maintain its physiological functions. These remodeling processes ultimately leads to ischemic cardiomyopathy and heart failure (HF). Recent therapeutic approaches (e.g., regenerative and nanomedicine) have shown promise to prevent HF postmyocardial infarction in animal models. However, these preclinical, clinical, and technological advancements have yet to yield substantial enhancements in the survival rate and quality of life of patients with severe ischemic injuries. This could be attributed largely to the considerable gap in knowledge between clinicians and nanobioengineers. Development of highly effective cardiac regenerative therapies requires connecting and coordinating multiple fields, including cardiology, cellular and molecular biology, biochemistry and chemistry, and mechanical and materials sciences, among others. This review is particularly intended to bridge the knowledge gap between cardiologists and regenerative nanomedicine experts. Establishing this multidisciplinary knowledge base may help pave the way for developing novel, safer, and more effective approaches that will enable the medical community to reduce morbidity and mortality in HF patients.
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Affiliation(s)
| | - Mehdi Mehrani
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Ahmad Amin
- Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Science Tehran, Iran
| | | | - Jessica C. Garbern
- Department of Stem Cell and Regenerative Biology, Harvard University, Harvard Stem Cell Institute, Cambridge, Massachusetts, United States
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, United States
| | - Giulio Caracciolo
- Department of Molecular Medicine, Sapienza University of Rome, V.le Regina Elena 291, 00161, Rome, Italy
| | - Steven Zanganeh
- Department of Radiology, Memorial Sloan Kettering, New York, NY 10065, United States
| | - Mitra Chitsazan
- Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Science Tehran, Iran
| | - Haniyeh Aghaverdi
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Seyed Mehdi Kamali Shahri
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Aliakbar Ashkarran
- Precision Health Program, Michigan State University, East Lansing, MI, United States
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Mohammad Raoufi
- Physical Chemistry I, Department of Chemistry and Biology & Research Center of Micro and Nanochemistry and Engineering, University of Siegen, Siegen, Germany
| | - Holly Bauser-Heaton
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Jianyi Zhang
- Department of Biomedical Engineering, The University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Jochen D. Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Anna Moore
- Precision Health Program, Michigan State University, East Lansing, MI, United States
| | - Richard T. Lee
- Department of Stem Cell and Regenerative Biology, Harvard University, Harvard Stem Cell Institute, Cambridge, Massachusetts, United States
- Department of Medicine, Division of Cardiology, Brigham and Women’s Hospital and Harvard Medical School, Cambridge, Massachusetts, United States
| | - Joseph C. Wu
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California, United States
- Institute of Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Vahid Serpooshan
- Department of Biomedical Engineering, Georgia Institute of Technology & Emory University School of Medicine, Atlanta, Georgia, United States
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Morteza Mahmoudi
- Precision Health Program, Michigan State University, East Lansing, MI, United States
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- Connors Center for Women’s Health & Gender Biology, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
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10
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Miller RJH, Thomson L, Levine R, Dimbil SJ, Patel J, Kobashigawa JA, Kransdorf E, Li D, Berman DS, Tamarappoo B. Quantitative myocardial tissue characterization by cardiac magnetic resonance in heart transplant patients with suspected cardiac rejection. Clin Transplant 2019; 33:e13704. [PMID: 31468570 PMCID: PMC6989053 DOI: 10.1111/ctr.13704] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/19/2019] [Accepted: 08/26/2019] [Indexed: 11/30/2022]
Abstract
Distinct histopathologic changes occur in acute cellular rejection (ACR), antibody-mediated rejection (AMR), and biopsy-negative rejection (BNR). Cardiovascular magnetic resonance (CMR)-based myocardial tissue characterization can be used to quantify these changes. We assessed T1, T2, and extracellular volume fraction (ECV) by CMR in patients with subtypes of rejection. T1, T2, and ECV were quantified at the mid-ventricular level and compared between patients with and without rejection. The association between quantitative tissue characteristics and the combined outcome of death, retransplantation, heart failure hospitalization, or myocardial infarction was evaluated with a Cox-proportional hazards model. In 46 patients, mean age 53.3 ± 13.7 years, 71.7% male, at a median of 7.4 years from transplant, average myocardial T1 was increased in BNR compared with no rejection (1057 vs 1012 msec, P = .006). Average myocardial T2 was elevated in all types of rejection, P < .05. In a cox-proportional hazards model, higher T2 values were associated with an increase in the combined clinical outcome (adjusted HR 1.21, 95% CI 1.06-1.37, P = .004) after adjusting for left ventricular mass index. Myocardial tissue characteristics are abnormal in all subtypes of rejection, and abnormal T2 quantified by CMR provides additional prognostic value.
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Affiliation(s)
- Robert JH Miller
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Louise Thomson
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ryan Levine
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Sadia J Dimbil
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Evan Kransdorf
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Debiao Li
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Balaji Tamarappoo
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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11
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Berhane H, Ruh A, Husain N, Robinson JD, Rigsby CK, Markl M. Myocardial velocity, intra-, and interventricular dyssynchrony evaluated by tissue phase mapping in pediatric heart transplant recipients. J Magn Reson Imaging 2019; 51:1212-1222. [PMID: 31515865 DOI: 10.1002/jmri.26916] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Endomyocardial biopsy (EMB) is the standard method for detecting allograft rejection in pediatric heart transplants (Htx). As EMB is invasive and carries a risk of complications, there is a need for a noninvasive alternative for allograft monitoring. PURPOSE To quantify left and right ventricular (LV & RV) peak velocities, velocity twist, and intra-/interventricular dyssynchrony using tissue phase mapping (TPM) in pediatric Htx compared with controls, and to explore the relationship between global cardiac function parameters and the number of rejection episodes to these velocities and intra-/interventricular dyssynchrony. STUDY TYPE Prospective. SUBJECTS Twenty Htx patients (age: 16.0 ± 3.1 years, 11 males) and 18 age- and sex-matched controls (age: 15.5 ± 4.3 years, nine males). FIELD STRENGTH/SEQUENCE 5T; 2D balanced cine steady-state free-precession (bSSFP), TPM (2D cine phase contrast with three-directional velocity encoding). ASSESSMENT LV and RV circumferential, radial, and long-axis velocity-time curves, global and segmental peak velocities were measured using TPM. Short-axis bSSFP images were used to measure global LV and RV function parameters. STATISTICAL TESTS A normality test (Lilliefors test) was performed on all data. For comparisons, a t-test was used for normally distributed data or a Wilcoxon rank-sum test otherwise. Correlations were determined by a Pearson correlation. RESULTS Htx patients had significantly reduced LV (P < 0.05-0.001) and RV (P < 0.05-0.001) systolic and diastolic global and segmental long-axis velocities, reduced RV diastolic peak twist (P < 0.01), and presented with higher interventricular dyssynchrony for long-axis and circumferential motions (P < 0.05-0.001). LV diastolic long-axis dyssynchrony (r = 0.48, P = 0.03) and RV diastolic peak twist (r = -0.64, P = 0.004) significantly correlated with the total number of rejection episodes. DATA CONCLUSION TPM detected differences in biventricular myocardial velocities in pediatric Htx patients compared with controls and indicated a relationship between Htx myocardial velocities and rejection history. LEVEL OF EVIDENCE 2 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2020;51:1212-1222.
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Affiliation(s)
- Haben Berhane
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Alexander Ruh
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nazia Husain
- Department of Pediatrics, Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Joshua D Robinson
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Pediatrics, Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Cynthia K Rigsby
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Michael Markl
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Chicago, Illinois, USA
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12
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Peng DM, Ding VY, Hollander SA, Khalapyan T, Dykes JC, Rosenthal DN, Almond CS, Sakarovitch C, Desai M, McElhinney DB. Long-term surveillance biopsy: Is it necessary after pediatric heart transplant? Pediatr Transplant 2019; 23:e13330. [PMID: 30506612 PMCID: PMC8063536 DOI: 10.1111/petr.13330] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 10/15/2018] [Accepted: 11/02/2018] [Indexed: 12/16/2022]
Abstract
Due to limited and conflicting data in pediatric patients, long-term routine surveillance endomyocardial biopsy (RSB) in pediatric heart transplant (HT) remains controversial. We sought to characterize the rate of positive RSB and determine factors associated with RSB-detected rejection. Records of patients transplanted at a single institution from 1995 to 2015 with >2 year of post-HT biopsy data were reviewed for RSB-detected rejections occurring >2 year post-HT. We illustrated the trajectory of significant rejections (ISHLT Grade ≥3A/2R) among total RSB performed over time and used multivariable logistic regression to model the association between time and risk of rejection. We estimated Kaplan-Meier freedom from rejection rates by patient characteristics and used the log-rank test to assess differences in rejection probabilities. We identified the best-fitting Cox proportional hazards regression model. In 140 patients, 86% did not have any episodes of significant RSB-detected rejection >2 year post-HT. The overall empirical rate of RSB-detected rejection >2 year post-HT was 2.9/100 patient-years. The percentage of rejection among 815 RSB was 2.6% and remained stable over time. Years since transplant remained unassociated with rejection risk after adjusting for patient characteristics (OR = 0.98; 95% CI 0.78-1.23; P = 0.86). Older age at HT was the only factor that remained significantly associated with risk of RSB-detected rejection under multivariable Cox analysis (P = 0.008). Most pediatric patients did not have RSB-detected rejection beyond 2 years post-HT, and the majority of those who did were older at time of HT. Indiscriminate long-term RSB in pediatric heart transplant should be reconsidered given the low rate of detected rejection.
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Affiliation(s)
- David M. Peng
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Betty Irene Moore Children’s Heart Center, Palo Alto, California
| | - Victoria Y. Ding
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Seth A. Hollander
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Betty Irene Moore Children’s Heart Center, Palo Alto, California
| | - Tigran Khalapyan
- Clinical and Translational Research Program, Palo Alto, California
| | - John C. Dykes
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Betty Irene Moore Children’s Heart Center, Palo Alto, California
| | - David N. Rosenthal
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Betty Irene Moore Children’s Heart Center, Palo Alto, California
| | - Christopher S. Almond
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Betty Irene Moore Children’s Heart Center, Palo Alto, California,Clinical and Translational Research Program, Palo Alto, California
| | - Charlotte Sakarovitch
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Manisha Desai
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Doff B. McElhinney
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Betty Irene Moore Children’s Heart Center, Palo Alto, California,Clinical and Translational Research Program, Palo Alto, California,Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
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13
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Zinn MD, Wallendorf MJ, Simpson KE, Osborne AD, Kirklin JK, Canter CE. Impact of routine surveillance biopsy intensity on the diagnosis of moderate to severe cellular rejection and survival after pediatric heart transplantation. Pediatr Transplant 2018; 22:e13131. [PMID: 29377465 PMCID: PMC5903932 DOI: 10.1111/petr.13131] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2017] [Indexed: 11/29/2022]
Abstract
Data are lacking on RSB intensity and outcomes after pediatric heart transplantation. PHTS centers received a survey on RSB practices from 2005 to present. PHTS data were obtained for 2010-2013 and integrated with center-matched survey responses for analysis. Survey response rate was 82.6% (38/46). Centers were classified as low-, moderate-, and high-intensity programs based on RSB frequency (0-more than 8 RSB/y). RSB intensity decreased with increasing time from HT. Age at HT impacted RSB intensity mostly in year 1, with little to no impact in later years. Most centers have not replaced RSB with non-invasive methods, but many added ECHO and biomarker monitoring. Higher RSB intensity was not associated with decreased 4-year mortality (P=.63) or earlier detection of moderate to severe (ISHLT grade 2R/3R) cellular rejection (RSBMSR) in the first year (P=.87). First-year RSBMSR incidence did not differ with intensity or age at HT. Significant variability exists in RSB intensity, but with no impact on timing and incidence of RSBMSR or 4-year mortality. Reduction in RSB frequency may be safe in certain patients after pediatric HT.
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Affiliation(s)
- Matthew D. Zinn
- Division of Cardiology; Department of Pediatrics; The University of Pittsburgh Medical Center; Pittsburgh PA USA
- Children's Hospital of Pittsburgh of UPMC; Pittsburgh PA USA
| | - Michael J. Wallendorf
- Division of Biostatistics; Washington University School of Medicine; St. Louis MO USA
| | - Kathleen E. Simpson
- Saint Louis Children's Hospital; St. Louis MO USA
- Division of Cardiology; Department of Pediatrics; Washington University School of Medicine; St. Louis MO USA
| | - Ashley D. Osborne
- Division of Cardiology; Department of Pediatrics; Washington University School of Medicine; St. Louis MO USA
| | - James K. Kirklin
- Division of Cardiothoracic Surgery; Department of Surgery; The University of Alabama at Birmingham; Birmingham AL USA
| | - Charles E. Canter
- Saint Louis Children's Hospital; St. Louis MO USA
- Division of Cardiology; Department of Pediatrics; Washington University School of Medicine; St. Louis MO USA
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14
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Weckbach LT, Maurer U, Schramm R, Huber BC, Lackermair K, Weiss M, Meiser B, Hagl C, Massberg S, Eifert S, Grabmaier U. Lower frequency routine surveillance endomyocardial biopsies after heart transplantation. PLoS One 2017; 12:e0182880. [PMID: 28841655 DOI: 10.1371/journal.pone.0182880] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 07/26/2017] [Indexed: 11/25/2022] Open
Abstract
In heart transplantation (HTx) patients, routine surveillance endomyocardial biopsies (rsEMB) are recommended for the detection of early cardiac allograft rejection. However, there is no consensus on the optimal frequency of rsEMB. Frequent rsEMB have shown a low diagnostic yield in the new era of potent immunosuppressive regimen. Efficacy and safety of lower frequency rsEMB have not been investigated so far. In this retrospective, single centre, observational study we evaluated 282 patients transplanted between 2004 and 2014. 218 of these patients were investigated by rsEMB and symptom-triggered EMB (stEMB). We evaluated EMB results, complications, risk factors for rejection, survival 1 and 5 years as well as incidence of cardiac allograft vasculopathy (CAV) 3 years after HTx. A mean of 7.1 ± 2.5 rsEMB were conducted per patient within the first year after HTx identifying 7 patients with asymptomatic and 9 patients with symptomatic acute rejection requiring glucocorticoide pulse therapy. Despite this relatively low frequency of rsEMB, only 6 unscheduled stEMB were required in the first year after HTx leading to 2 additional treatments. In 6 deaths among all 282 patients (2.1%), acute rejection could not be ruled out as a potential underlying cause. Overall survival at 1 year was 78.7% and 5-year survival was 74%. Incidence of CAV was 17% at 3-year follow-up. Morbidity and mortality of lower frequency rsEMB are comparable with data from the International Society for Heart and Lung Transplantation (ISHLT) registry. Consensus is needed on the optimal frequency of EMB.
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15
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Lander MM, Teuteberg J. Detecting Cardiac Allograft Rejection in the Era of Personalized Medicine: a Review of Current Genomic Surveillance Techniques. Curr Transpl Rep 2016; 3:367-374. [DOI: 10.1007/s40472-016-0125-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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16
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Fujino M, Zhu P, Cai S, Nishio Y, Zhuang J, Li XK. MicroRNAs Involved in Acute Rejection and Tolerance in Murine Cardiac Allografts. EXP CLIN TRANSPLANT 2016; 14:424-30. [PMID: 27227980 DOI: 10.6002/ect.2015.0251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Induction of immunologic tolerance is the ultimate goal of organ transplant. To investigate the involvement of microRNA in tolerance induction after organ transplant, murine cardiac allografts were performed and the expression of microRNA in the grafts was analyzed. MATERIALS AND METHODS Cardiac allografts were performed using C57BL/10 (H2-Kb) to CBA/N (H2-Kk) fully mismatched combination with or without eicosapentaenoic acid for tolerance induction. Ten microRNA, mir-146a, 15b, 223, 23a, 27a, 34a, 451, 101a, 101b, 148a, discovered in hepatic grafts were examined by quantitative reverse transcription polymerase chain reaction using RNA from the cardiac allografts. RESULTS The administration of eicosapentaenoic acid markedly prolonged the cardiac allograft survival (median survival time > 100 days) and decreased the pathological score. Quantitative reverse transcription polymerase chain reaction revealed that mir-223 was up-regulated in accordance with pathological deterioration as compared with the expression observed in the syngeneic grafts. In contrast, the other microRNA was down-regulated. Pearson product moment correlation analysis demonstrated that the expression patterns of mir-223 and mir-146a had high or moderate positive associations between the cardiac and haptic allografts in mice. CONCLUSIONS The change in the microRNA expression in the allografts suggests that microRNA plays a role in the induction and/or maintenance of tolerance after allograft transplant. Our findings suggest that mir-223 may be associated with rejection while mir-146a, -15b, -23a, -27a, -34a, -451, -101a, -101b, -148a may be involved in tolerance. A superior grasp of the mechanism for rejection and tolerance observed in the murine heart allotransplant model may provide a better curative treatment strategy to mitigate allograft rejection.
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Affiliation(s)
- Masayuki Fujino
- rom the Division of Transplantation Immunology National Research Institute for Child Health and Development; and the AIDS Research Center National Institute of Infectious Diseases Tokyo Japan
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17
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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18
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Butler CR, Savu A, Bakal JA, Toma M, Thompson R, Chow K, Wang H, Kim DH, Mengel M, Haykowsky M, Pearson GJ, Kaul P, Paterson I. Correlation of cardiovascular magnetic resonance imaging findings and endomyocardial biopsy results in patients undergoing screening for heart transplant rejection. J Heart Lung Transplant 2015; 34:643-50. [PMID: 25934478 DOI: 10.1016/j.healun.2014.12.020] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 11/24/2014] [Accepted: 12/17/2014] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Endomyocardial biopsy (EMB) is the current gold standard to screen for heart transplant rejection but has important risks and limitations. Cardiovascular magnetic resonance imaging (CMRI) is increasingly used to characterize cardiac function and myocardial tissue. We evaluated the diagnostic accuracy of CMRI compared with EMB and clinically diagnosed heart transplant rejection. METHODS Comprehensive CMRI scans were performed on adult heart transplant recipients within 24 hours of EMB (routine or clinically indicated), before initiation of any anti-rejection therapy, and blinded to EMB results. Multivariable analysis was used to create CMRI diagnostic criteria for comparison with a positive EMB (Grade ≥ 2R or antibody-mediated rejection) and clinical rejection (change in medical therapy to treat rejection). RESULTS Sixty participants (75% male; mean age, 51 ± 14 years) were recruited, providing 73 comparisons between CMRI and EMB for the diagnosis of rejection. Multivariable logistic regression identified myocardial edema (T2 relaxation time) and right ventricular end-diastolic volume index as independent predictors of a positive EMB. Combining threshold right ventricular end-diastolic volume index and edema values predicted a positive EMB with very good accuracy: sensitivity, 93%; specificity, 78%; positive predictive value, 52%; and negative predictive valve, 98%. CMRI was more sensitive than EMB at predicting clinical rejection (sensitivity of 67% vs 58%). CONCLUSIONS CMRI has high sensitivity and high negative predictive value in predicting biopsy-positive heart transplant rejection and may be useful as a screening test before routine EMB. CMRI also has better sensitivity for clinically diagnosed heart transplant rejection and could be helpful in cases of negative rejection on the biopsy specimen.
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Affiliation(s)
- Craig R Butler
- Division of Cardiology, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - AnaMaria Savu
- Division of Cardiology, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | | | - Mustafa Toma
- Division of Cardiology, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | | | | | - Harris Wang
- Division of Cardiology, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Daniel H Kim
- Division of Cardiology, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | | | - Mark Haykowsky
- Department of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Glen J Pearson
- Division of Cardiology, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Padma Kaul
- Division of Cardiology, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Ian Paterson
- Division of Cardiology, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada.
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Awad M, Ruzza A, Soliman C, Pinzás J, Marban E, Trento A, Czer L. Endomyocardial Biopsy Technique for Orthotopic Heart Transplantation and Cardiac Stem-Cell Harvesting. Transplant Proc 2014; 46:3580-4. [DOI: 10.1016/j.transproceed.2014.05.084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 05/27/2014] [Indexed: 11/29/2022]
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20
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Lampert BC, Teuteberg JJ, Shullo MA, Holtz J, Smith KJ. Cost-Effectiveness of Routine Surveillance Endomyocardial Biopsy After 12 Months Post–Heart Transplantation. Circ Heart Fail 2014; 7:807-13. [DOI: 10.1161/circheartfailure.114.001199] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Despite low risk of late rejection after heart transplant (HT), surveillance endomyocardial biopsies (EMBs) are often continued for years. We assessed the cost-effectiveness of routine EMB after 12 months post-HT.
Methods and Results—
Markov model compared the following surveillance EMB strategies to baseline strategy of stopping EMB 12 months post-HT: (1) every 4 months during year 2 post-HT, (2) every 6 months during year 2, (3) every 4 months for years 2 to 3, and (4) every 6 months for years 2 to 3. Patients entered the model 12 months post-HT and were followed until 36 months. In all strategies, patients had EMB with symptoms; in biopsy strategies after 12 months, EMB was also performed as scheduled regardless of symptoms. One-way and Monte Carlo sensitivity analyses were performed. Stopping EMB at 12 months was dominant (more effective, less costly), saving $2884 per patient compared with the next best strategy (every 6 months for year 2) and gaining 0.0011 quality-adjusted life-years. Increasing the annual risk of asymptomatic rejection in years 2 to 3 from previously reported 2.5% to 8.5% resulted in the biopsy every 6 months for year 2 strategy gaining 0.0006 quality-adjusted life-years, but cost $4 913 599 per quality-adjusted life-year gained. EMB for 12 months was also no longer dominant when mortality risk from untreated asymptomatic rejection approached 11%; competing strategies still cost >$200 000 per quality-adjusted life-year as that risk approached 99%.
Conclusions—
Surveillance EMB for 12 months post-HT is more effective and less costly than EMB performed after 12 months, unless risks of asymptomatic cellular rejection and its mortality are strikingly higher than previously observed.
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Affiliation(s)
- Brent C. Lampert
- From the Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus (B.C.L.); Heart and Vascular Institute (J.J.T., J.H.), Pharmacy and Therapeutics (M.A.S.), and Division of General Internal Medicine (K.J.S.), University of Pittsburgh, PA
| | - Jeffrey J. Teuteberg
- From the Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus (B.C.L.); Heart and Vascular Institute (J.J.T., J.H.), Pharmacy and Therapeutics (M.A.S.), and Division of General Internal Medicine (K.J.S.), University of Pittsburgh, PA
| | - Michael A. Shullo
- From the Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus (B.C.L.); Heart and Vascular Institute (J.J.T., J.H.), Pharmacy and Therapeutics (M.A.S.), and Division of General Internal Medicine (K.J.S.), University of Pittsburgh, PA
| | - Jonathan Holtz
- From the Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus (B.C.L.); Heart and Vascular Institute (J.J.T., J.H.), Pharmacy and Therapeutics (M.A.S.), and Division of General Internal Medicine (K.J.S.), University of Pittsburgh, PA
| | - Kenneth J. Smith
- From the Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus (B.C.L.); Heart and Vascular Institute (J.J.T., J.H.), Pharmacy and Therapeutics (M.A.S.), and Division of General Internal Medicine (K.J.S.), University of Pittsburgh, PA
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Duong Van Huyen JP, Tible M, Gay A, Guillemain R, Aubert O, Varnous S, Iserin F, Rouvier P, François A, Vernerey D, Loyer X, Leprince P, Empana JP, Bruneval P, Loupy A, Jouven X. MicroRNAs as non-invasive biomarkers of heart transplant rejection. Eur Heart J 2014; 35:3194-202. [PMID: 25176944 DOI: 10.1093/eurheartj/ehu346] [Citation(s) in RCA: 142] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM Rejection is one of the major causes of late cardiac allograft failure and at present can only be diagnosed by invasive endomyocardial biopsies. We sought to determine whether microRNA profiling could serve as a non-invasive biomarker of cardiac allograft rejection. METHODS We included 113 heart transplant recipients from four referral French institutions (test cohort, n = 60, validation cohort, n = 53). In the test cohort, we compared patients with acute biopsy-proven allograft rejection (n = 30) to matched control patients without rejection (n = 30), by assessing microRNAs expression in the heart allograft tissue and patients concomitant serum using RNA extraction and qPCR analysis. Fourteen miRNAs were selected on the basis of their implication in allograft rejection, endothelial activation, and inflammation and tissue specificity. RESULTS We identified seven miRNAs that were differentially expressed between normal and rejecting heart allografts: miR-10a, miR-21, miR-31, miR-92a, miR-142-3p miR-155, and miR-451 (P < 0.0001 for all comparisons). Four out of seven miRNAs also showed differential serological expression (miR-10a, miR-31, miR-92a, and miR-155) with strong correlation with their tissular expression. The receiver-operating characteristic analysis showed that these four circulating miRNAs strongly discriminated patients with allograft rejection from patients without rejection: miR-10a (AUC = 0.975), miR-31 (AUC = 0.932), miR-92a (AUC = 0.989), and miR-155 (AUC = 0.998, P < 0.0001 for all comparisons). We confirmed in the external validation set that these four miRNAs highly discriminated patients with rejection from those without. The discrimination capability of the four miRNAs remained significant when stratified by rejection diagnosis (T-cell-mediated rejection or antibody-mediated rejection) and time post-transplant. CONCLUSION This study demonstrates that a differential expression of miRNA occurs in rejecting allograft patients, not only at the tissue level but also in the serum, suggesting their potential relevance as non-invasive biomarkers in heart transplant rejection.
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Affiliation(s)
- Jean-Paul Duong Van Huyen
- Paris Translational Research Center for Organ Transplantation, INSERM UMR 970, Biostatistics and Histopathology Platform, PARCC Cardiovascular Research Institute, Paris F-75015, France Université Sorbonne Paris Cité, France Department of Pathology, Necker Hospital, APHP, Paris F-75015, France
| | - Marion Tible
- Paris Translational Research Center for Organ Transplantation, INSERM UMR 970, Biostatistics and Histopathology Platform, PARCC Cardiovascular Research Institute, Paris F-75015, France Université Sorbonne Paris Cité, France
| | - Arnaud Gay
- Cardio-Thoracic Surgery Unit and Pathology Department, Rouen University Hospital, France
| | - Romain Guillemain
- Department of Pathology and Department of Cardiovascular Surgery, Hôpital Européen Georges Pompidou, APHP, Paris F-75015, France
| | - Olivier Aubert
- Paris Translational Research Center for Organ Transplantation, INSERM UMR 970, Biostatistics and Histopathology Platform, PARCC Cardiovascular Research Institute, Paris F-75015, France
| | - Shaida Varnous
- Cardio-Thoracic Surgery Unit and Pathology Department, La Pitié-Salpétrière, APHP, Paris F-75013, France
| | - Franck Iserin
- Departement of Cardiology, Necker Hospital, APHP, Paris F-75015, France
| | - Philippe Rouvier
- Cardio-Thoracic Surgery Unit and Pathology Department, La Pitié-Salpétrière, APHP, Paris F-75013, France
| | - Arnaud François
- Cardio-Thoracic Surgery Unit and Pathology Department, Rouen University Hospital, France
| | - Dewi Vernerey
- Paris Translational Research Center for Organ Transplantation, INSERM UMR 970, Biostatistics and Histopathology Platform, PARCC Cardiovascular Research Institute, Paris F-75015, France
| | - Xavier Loyer
- Paris Translational Research Center for Organ Transplantation, INSERM UMR 970, Biostatistics and Histopathology Platform, PARCC Cardiovascular Research Institute, Paris F-75015, France
| | - Pascal Leprince
- Cardio-Thoracic Surgery Unit and Pathology Department, La Pitié-Salpétrière, APHP, Paris F-75013, France
| | - Jean-Philippe Empana
- Paris Translational Research Center for Organ Transplantation, INSERM UMR 970, Biostatistics and Histopathology Platform, PARCC Cardiovascular Research Institute, Paris F-75015, France
| | - Patrick Bruneval
- Paris Translational Research Center for Organ Transplantation, INSERM UMR 970, Biostatistics and Histopathology Platform, PARCC Cardiovascular Research Institute, Paris F-75015, France Université Sorbonne Paris Cité, France Department of Pathology and Department of Cardiovascular Surgery, Hôpital Européen Georges Pompidou, APHP, Paris F-75015, France
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, INSERM UMR 970, Biostatistics and Histopathology Platform, PARCC Cardiovascular Research Institute, Paris F-75015, France Université Sorbonne Paris Cité, France
| | - Xavier Jouven
- Paris Translational Research Center for Organ Transplantation, INSERM UMR 970, Biostatistics and Histopathology Platform, PARCC Cardiovascular Research Institute, Paris F-75015, France Université Sorbonne Paris Cité, France
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Mazimba S, Tallaj JA, George JF, Kirklin JK, Brown RN, Pamboukian SV. Infection and rejection risk after cardiac transplantation with induction vs. no induction: a multi-institutional study. Clin Transplant 2014; 28:946-52. [DOI: 10.1111/ctr.12395] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Sula Mazimba
- Division of Cardiovascular Diseases; University of Alabama at Birmingham; Birmingham AL USA
| | - Jose A. Tallaj
- Division of Cardiovascular Diseases; University of Alabama at Birmingham; Birmingham AL USA
| | - James F. George
- Division of Cardiothoracic Surgery; University of Alabama at Birmingham; Birmingham AL USA
| | - James K. Kirklin
- Division of Cardiothoracic Surgery; University of Alabama at Birmingham; Birmingham AL USA
| | - Robert N. Brown
- Division of Cardiothoracic Surgery; University of Alabama at Birmingham; Birmingham AL USA
| | - Salpy V. Pamboukian
- Division of Cardiovascular Diseases; University of Alabama at Birmingham; Birmingham AL USA
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23
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Hill DA, Drazner MH, de Lemos JA. 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] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ueno T, Dutta P, Keliher E, Leuschner F, Majmudar M, Marinelli B, Iwamoto Y, Figueiredo JL, Christen T, Swirski FK, Libby P, Weissleder R, Nahrendorf M. Nanoparticle PET-CT detects rejection and immunomodulation in cardiac allografts. Circ Cardiovasc Imaging 2013; 6:568-73. [PMID: 23771986 DOI: 10.1161/circimaging.113.000481] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Macrophages predominate among the inflammatory cells in rejecting allografts. These innate immune cells, in addition to allospecific T cells, can damage cardiomyocytes directly. METHODS AND RESULTS We explored whether sensitive positron emission tomography-computed tomography (PET-CT) imaging of macrophages-avid nanoparticles detects rejection of heart allografts in mice. In addition, we used the imaging method to follow the immunomodulatory impact of angiotensin-converting enzyme inhibitor therapy on myeloid cells in allografts. Dextran nanoparticles were derivatized with the PET isotope copper-64 and imaged 7 days after transplantation. C57BL/6 recipients of BALB/c allografts displayed robust positron emission tomography signal (standard uptake value allograft, 2.8±0.3; isograft control, 1.7±0.2; P<0.05). Autoradiography and scintillation counting confirmed the in vivo findings. We then imaged the effects of angiotensin-converting enzyme inhibitor (5 mg/kg enalapril). Angiotensin-converting enzyme inhibitor significantly decreased nanoparticle signal (P<0.05). Histology and flow cytometry showed a reduced number of myeloid cells in the graft, blood, and lymph nodes and diminished antigen presentation (P<0.05 versus untreated allografts). Angiotensin-converting enzyme inhibitor also significantly prolonged allograft survival (12 versus 7 days; P<0.0001). CONCLUSIONS Nanoparticle macrophage PET-CT detects heart transplant rejection and predicts organ survival by reporting on myeloid cells.
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Affiliation(s)
- Takuya Ueno
- Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Bernhardt A, Reichenspurner H. Zur ISHLT-Leitlinie: Immunsuppression nach Herztransplantation. Z Herz- Thorax- Gefäßchir 2013. [DOI: 10.1007/s00398-012-0985-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ouyang B, Sinha D, Slate EH, Van Bakel AB. Bayesian analysis of recurrent event with dependent termination: an application to a heart transplant study. Stat Med 2012; 32:2629-42. [PMID: 23280968 DOI: 10.1002/sim.5717] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 12/03/2012] [Indexed: 11/08/2022]
Abstract
For a heart transplant patient, the risk of graft rejection and risk of death are likely to be associated. Two fully specified Bayesian models for recurrent events with dependent termination are applied to investigate the potential relationships between these two types of risk as well as association with risk factors. We particularly focus on the choice of priors, selection of the appropriate prediction model, and prediction methods for these two types of risk for an individual patient. Our prediction tools can be easily implemented and helpful to physicians for setting heart transplant patients' biopsy schedule.
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Affiliation(s)
- Bichun Ouyang
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison St., Ste. 755, Chicago, IL 60612, USA.
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Usman AA, Taimen K, Wasielewski M, McDonald J, Shah S, Giri S, Cotts W, McGee E, Gordon R, Collins JD, Markl M, Carr JC. Cardiac magnetic resonance T2 mapping in the monitoring and follow-up of acute cardiac transplant rejection: a pilot study. Circ Cardiovasc Imaging 2012; 5:782-90. [PMID: 23071145 DOI: 10.1161/circimaging.111.971101] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Acute rejection is a major factor impacting survival in the first 12 months after cardiac transplantation. Transplant monitoring requires invasive techniques. Cardiac magnetic resonance (CMR), noninvasive testing, has been used in monitoring heart transplants. Prolonged T2 relaxation has been related to transplant edema and possibly rejection. We hypothesize that prolonged T2 reflects transplant rejection and that quantitative T2 mapping will concur with the pathological and clinical findings of acute rejection. METHODS AND RESULTS Patients were recruited within the first year after transplantation. Biopsies were graded according to the International Society for Heart Lung Transplant system for cellular rejection with immunohistochemistry for humoral rejection. Rejection was also considered if patients presented with signs and symptoms of hemodynamic compromise without biopsy evidence of rejection who subsequently improved with treatment. Patients underwent a novel single-shot T2-prepared steady-state free precession 4-chamber and 3 short axis sequences and regions of interest were drawn overlying T2 maps by 2 independent blinded reviewers. A total of 74 (68 analyzable) CMRs T2 maps in 53 patients were performed. There were 4 cellular, 2 humoral, and 2 hemodynamic rejection cases. The average T2 relaxation time for grade 0R (n=46) and grade 1R (n=17) was 52.5±2.2 and 53.1±3.3 ms (mean±SD), respectively. The average T2 relaxation for grade 2R (n=3) was 59.6±3.1 ms and 3R (n=1) was 60.3 ms (all P value <0.05 compared with controls). The T2 average in humoral rejection cases (n=2) was 59.2±3.3 ms and the hemodynamic rejection (n=2) was 61.1±1.8 ms (P<0.05 versus controls). The average T2 relaxation time for all-cause rejection versus no rejection is 60.1±2.1 versus 52.8±2.7 ms (P<0.05). All rejection cases were rescanned 2.5 months after treatment and demonstrated T2 normalization with average of 51.4±1.6 ms. No difference was found in ventricular function between nonrejection and rejection patients, except in ventricular mass 107.8±10.3 versus 127.5±10.4 g (P < 0.05). CONCLUSIONS Quantitative T2 mapping offers a novel noninvasive tool for transplant monitoring, and these initial findings suggest potential use in characterizing rejections. Given the limited numbers, a larger multi-institution study may help elucidate the benefits of T2 mapping as an adjunctive tool in routine monitoring of cardiac transplants.
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Affiliation(s)
- Asad A Usman
- Department of Radiology, Cardiovascular Imaging, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
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Markl M, Rustogi R, Galizia M, Goyal A, Collins J, Usman A, Jung B, Foell D, Carr J. Myocardial T2-mapping and velocity mapping: Changes in regional left ventricular structure and function after heart transplantation. Magn Reson Med 2012; 70:517-26. [DOI: 10.1002/mrm.24472] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 07/20/2012] [Accepted: 08/03/2012] [Indexed: 11/08/2022]
Affiliation(s)
- Michael Markl
- Department of Radiology; Feinberg School of Medicine; Northwestern University; Chicago Illinois USA
- Department of Biomedical Engineering; McCormick School of Engineering; Northwestern University; Chicago Illinois USA
| | - Rahul Rustogi
- Department of Radiology; Feinberg School of Medicine; Northwestern University; Chicago Illinois USA
| | - Mauricio Galizia
- Department of Radiology; Feinberg School of Medicine; Northwestern University; Chicago Illinois USA
| | - Amita Goyal
- Department of Radiology; Feinberg School of Medicine; Northwestern University; Chicago Illinois USA
| | - Jeremy Collins
- Department of Radiology; Feinberg School of Medicine; Northwestern University; Chicago Illinois USA
| | - Asad Usman
- Department of Radiology; Feinberg School of Medicine; Northwestern University; Chicago Illinois USA
| | - Bernd Jung
- Department of Medical Physics; Freiburg University Medical Center; Freiburg Germany
| | - Daniela Foell
- Department of Cardiology; Freiburg University Medical Center; Freiburg Germany
| | - James Carr
- Department of Radiology; Feinberg School of Medicine; Northwestern University; Chicago Illinois USA
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Daly KP, Marshall AC, Vincent JA, Zuckerman WA, Hoffman TM, Canter CE, Blume ED, Bergersen L. Endomyocardial biopsy and selective coronary angiography are low-risk procedures in pediatric heart transplant recipients: results of a multicenter experience. J Heart Lung Transplant 2011; 31:398-409. [PMID: 22209354 DOI: 10.1016/j.healun.2011.11.019] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 10/31/2011] [Accepted: 11/25/2011] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND No prior reports documenting the safety and diagnostic yield of cardiac catheterization and endomyocardial biopsy (EMB) in heart transplant recipients include multicenter data. METHODS Data on the safety and diagnostic yield of EMB procedures performed in heart transplant recipients were recorded in the Congenital Cardiac Catheterization Outcomes Project database at 8 pediatric centers during a 3-year period. Adverse events (AEs) were classified according to a 5-level severity scale. Generalized estimating equation models identified risk factors for high-severity AEs (HSAEs; Levels 3-5) and non-diagnostic biopsy samples. RESULTS A total of 2,665 EMB cases were performed in 744 pediatric heart transplant recipients (median age, 12 years [interquartile range, 4.8, 16.7]; 54% male). AEs occurred in 88 cases (3.3%), of which 28 (1.1%) were HSAEs. AEs attributable to EMB included tricuspid valve injury, transient complete heart block, and right bundle branch block. Amongst 822 cases involving coronary angiography, 10 (1.2%) resulted in a coronary-related AE. There were no myocardial perforations or deaths. Multivariable risk factors for HSAEs included fewer prior catheterizations (p = 0.006) and longer case length (p < 0.001). EMB yielded sufficient tissue for diagnosis in 99% of cases. Longer time since heart transplant was the most significant predictor of a non-diagnostic biopsy sample (p < 0.001). CONCLUSIONS In the current era, cardiac catheterizations involving EMB can be performed in pediatric heart transplant recipients with a low AE rate and high diagnostic yield. Risk of HSAEs is increased in early post-transplant biopsies and with longer case length. Longer time since heart transplant is associated with non-diagnostic EMB samples.
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Affiliation(s)
- Kevin P Daly
- Department of Cardiology, Children's Hospital Boston and the Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
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Abstract
Heart transplantation is now an established treatment for patients suffering from end-stage heart diseases. With the advances in immunosuppressive treatment, the survival rate for transplant patients has improved greatly. However, allograft rejection, both acute and chronic, after heart transplantation is still a limitation leading to morbidity and mortality. The current clinical gold standard for screening rejection is endomyocardial biopsy (EMB), which is not only invasive, but also error-prone, due to the limited sample size and the site location of sampling. It would be highly desirable to have reliable and noninvasive alternatives for EMB in monitoring cardiac allograft rejection. The objective of this review is to highlight how cardiovascular imaging can contribute to noninvasively detecting and to evaluating both acute and chronic allograft rejection after heart transplantation, in particular, cardiovascular MRI (CMRI); and how CMRI can assess both immune cell infiltration at the rejecting organ, and the cardiac dysfunctions resulting from allograft rejection.
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Swirski FK, Wildgruber M, Ueno T, Figueiredo JL, Panizzi P, Iwamoto Y, Zhang E, Stone JR, Rodriguez E, Chen JW, Pittet MJ, Weissleder R, Nahrendorf M. Myeloperoxidase-rich Ly-6C+ myeloid cells infiltrate allografts and contribute to an imaging signature of organ rejection in mice. J Clin Invest 2010; 120:2627-34. [PMID: 20577051 DOI: 10.1172/jci42304] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Accepted: 04/28/2010] [Indexed: 11/17/2022] Open
Abstract
Rates of graft rejection are high among recipients of heart transplants. The onset and progression of clinically significant heart transplant rejection are currently monitored by serial biopsy, but this approach is highly invasive and lacks sensitivity. Here, we have developed what we believe to be a new technique to measure organ rejection noninvasively that involves the exploration of tissue-infiltrating leukocytes as biomarker sources for diagnostic imaging. Specifically, we profiled the myeloid response in a murine model of heart transplantation with the aim of defining and validating an imaging signature of graft rejection. Ly-6Chi monocytes, which promote inflammation, accumulated progressively in allografts but only transiently in isografts. Ly-6Clo monocytes, which help resolve inflammation, did not accumulate, although they composed the majority of the few remaining monocytes in isografts. The persistence of Ly-6Chi monocytes in allografts prompted us to screen for a Ly-6Chi monocyte-associated imaging marker. Low-density array data revealed that Ly-6Chi monocytes express 10-fold higher levels of myeloperoxidase (MPO) than Ly-6Clo monocytes. Noninvasive magnetic resonance imaging of MPO with an MPO-activatable Gd-chelate revealed a spatially defined T1-weighted signal in rejected allografts but not in isografts or MPO-deficient allograft recipients. Flow cytometry, enzymography, and histology validated the approach by mapping MPO activity to Ly-6Chi monocytes and neutrophils. Thus, MPO imaging represents a potential alternative to the current invasive clinical standard by which transplants are monitored.
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Affiliation(s)
- Filip K Swirski
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Pham MX, Teuteberg JJ, Kfoury AG, Starling RC, Deng MC, Cappola TP, Kao A, Anderson AS, Cotts WG, Ewald GA, Baran DA, Bogaev RC, Elashoff B, Baron H, Yee J, Valantine HA. Gene-expression profiling for rejection surveillance after cardiac transplantation. N Engl J Med 2010; 362:1890-900. [PMID: 20413602 DOI: 10.1056/nejmoa0912965] [Citation(s) in RCA: 348] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endomyocardial biopsy is the standard method of monitoring for rejection in recipients of a cardiac transplant. However, this procedure is uncomfortable, and there are risks associated with it. Gene-expression profiling of peripheral-blood specimens has been shown to correlate with the results of an endomyocardial biopsy. METHODS We randomly assigned 602 patients who had undergone cardiac transplantation 6 months to 5 years previously to be monitored for rejection with the use of gene-expression profiling or with the use of routine endomyocardial biopsies, in addition to clinical and echocardiographic assessment of graft function. We performed a noninferiority comparison of the two approaches with respect to the composite primary outcome of rejection with hemodynamic compromise, graft dysfunction due to other causes, death, or retransplantation. RESULTS During a median follow-up period of 19 months, patients who were monitored with gene-expression profiling and those who underwent routine biopsies had similar 2-year cumulative rates of the composite primary outcome (14.5% and 15.3%, respectively; hazard ratio with gene-expression profiling, 1.04; 95% confidence interval, 0.67 to 1.68). The 2-year rates of death from any cause were also similar in the two groups (6.3% and 5.5%, respectively; P=0.82). Patients who were monitored with the use of gene-expression profiling underwent fewer biopsies per person-year of follow-up than did patients who were monitored with the use of endomyocardial biopsies (0.5 vs. 3.0, P<0.001). CONCLUSIONS Among selected patients who had received a cardiac transplant more than 6 months previously and who were at a low risk for rejection, a strategy of monitoring for rejection that involved gene-expression profiling, as compared with routine biopsies, was not associated with an increased risk of serious adverse outcomes and resulted in the performance of significantly fewer biopsies. (ClinicalTrials.gov number, NCT00351559.)
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Affiliation(s)
- Michael X Pham
- Stanford University Medical Center, Stanford, California, USA
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Butler CR, Thompson R, Haykowsky M, Toma M, Paterson I. Cardiovascular magnetic resonance in the diagnosis of acute heart transplant rejection: a review. J Cardiovasc Magn Reson 2009; 11:7. [PMID: 19284612 PMCID: PMC2660322 DOI: 10.1186/1532-429x-11-7] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Accepted: 03/12/2009] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Screening for organ rejection is a critical component of care for patients who have undergone heart transplantation. Endomyocardial biopsy is the gold standard screening tool, but non-invasive alternatives are needed. Cardiovascular magnetic resonance (CMR) is well suited to provide an alternative to biopsy because of its ability to quantify ventricular function, morphology, and characterize myocardial tissue. CMR is not widely used to screen for heart transplant rejection, despite many trials supporting its use for this indication. This review summarizes the different CMR sequences that can detect heart transplant rejection as well as the strengths and weaknesses of their application. RESULTS T2 quantification by spin echo techniques has been criticized for poor reproducibility, but multiple studies show its utility in screening for rejection. Human and animal data estimate that T2 quantification can diagnose rejection with sensitivities and specificities near 90%. There is also a suggestion that T2 quantification can predict rejection episodes in patients with normal endomyocardial biopsies.T1 quantification has also shown association with biopsy proven rejection in a small number of trials. T1 weighted gadolinium early enhancement appeared promising in animal data, but has had conflicting results in human trials. Late gadolinium enhancement in the diagnosis of rejection has not been evaluated.CMR derived measures of ventricular morphology and systolic function have insufficient sensitivity to diagnose mild to moderate rejection. CMR derived diastolic function can demonstrate abnormalities in allografts compared to native human hearts, but its ability to diagnose rejection has not yet been tested.There is promising animal data on the ability of iron oxide contrast agents to illustrate the changes in vascular permeability and macrophage accumulation seen in rejection. Despite good safety data, these contrast agents have not been tested in the human heart transplant population. CONCLUSION T2 quantification has demonstrated the best correlation to biopsy proven heart transplant rejection. Further studies evaluating diastolic function, late gadolinium enhancement, and iron oxide contrast agents to diagnose rejection are needed. Future studies should focus on combining multiple CMR measures into a transplant rejection scoring system which would improve sensitivity and possibly reduce, if not eliminate, the need for endomyocardial biopsy.
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Affiliation(s)
- Craig R Butler
- Division of Cardiology, University of Alberta, Edmonton, AB, Canada
| | - Richard Thompson
- Department of Biomedical Engineering, University of Alberta, Edmonton, AB, Canada
| | - Mark Haykowsky
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Mustafa Toma
- Division of Cardiology, University of Alberta, Edmonton, AB, Canada
| | - Ian Paterson
- Division of Cardiology, University of Alberta, Edmonton, AB, Canada
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Hamour IM, Burke MM, Bell AD, Panicker MG, Banerjee R, Banner NR. 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] [What about the content of this article? (0)] [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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Pham MX, Deng MC, Kfoury AG, Teuteberg JJ, Starling RC, Valantine H. Molecular Testing for Long-term Rejection Surveillance in Heart Transplant Recipients: Design of the Invasive Monitoring Attenuation Through Gene Expression (IMAGE) Trial. J Heart Lung Transplant 2007; 26:808-14. [PMID: 17692784 DOI: 10.1016/j.healun.2007.05.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2007] [Revised: 05/09/2007] [Accepted: 05/28/2007] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Acute rejection continues to occur beyond the first year after cardiac transplantation, but the optimal strategy for detecting rejection during this late period is still controversial. Gene expression profiling (GEP), with its high negative predictive value for acute cellular rejection (ACR), appears to be well suited to identify low-risk patients who can be safely managed without routine invasive endomyocardial biopsy (EMB). METHODS The Invasive Monitoring Attenuation Through Gene Expression (IMAGE) study is a prospective, multicenter, non-blinded, randomized clinical trial designed to test the hypothesis that a primarily non-invasive rejection surveillance strategy utilizing GEP testing is not inferior to an invasive EMB-based strategy with respect to cardiac allograft dysfunction, rejection with hemodynamic compromise (HDC) and all-cause mortality. RESULTS A total of 199 heart transplant recipients in their second through fifth post-transplant years have been enrolled in the IMAGE study since January 13, 2005. The study is expected to continue through 2008. CONCLUSIONS The IMAGE study is the first randomized, controlled comparison of two rejection surveillance strategies measuring outcomes in heart transplant recipients who are beyond their first year post-transplant. The move away from routine histologic evaluation for allograft rejection represents an important paradigm shift in cardiac transplantation, and the results of this study have important implications for the future management of heart transplant patients.
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Affiliation(s)
- Michael X Pham
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California 94305, USA
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Fang KC. Clinical utilities of peripheral blood gene expression profiling in the management of cardiac transplant patients. J Immunotoxicol 2007; 4:209-17. [PMID: 18958730 PMCID: PMC2409185 DOI: 10.1080/15476910701385570] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2006] [Accepted: 03/13/2007] [Indexed: 10/30/2022] Open
Abstract
Cardiac allografts induce host immune responses that lead to endomyocardial tissue injury and progressive graft dysfunction. Inflammatory cell infiltration and myocyte damage characterize acute cellular rejection (ACR) that presents episodically in either a subclinical or symptom-associated manner. Sampling of the endomyocardium by transvenous biopsy enables pathologic grading using light microscopic criteria to distinguish severity based on the focality or diffuseness of inflammation and associated myocyte injury. Monitoring for ACR utilizes endomyocardial biopsy in conjunction with history and physical examination and assessment of allograft function by echocardiography. However, procedural and interpretive issues limit the diagnostic certainty provided by endomyocardial biopsy. The dynamic profiling of genes expressed by peripheral blood mononuclear cells (PBMCs) enables quantitative assessments of intracellular mRNA whose levels fluctuate during systemic alloimmune responses. Gene expression profiling of PBMCs using a multi-gene ACR classifier enables the AlloMap molecular expression test to distinguish moderate to severe ACR (p = 0.0018) in heart transplant patients. The AlloMap test provides molecular insights into a patient's risk for ACR by distilling the aggregate expression levels of its informative genes into a single score on a scale of 0 to 40. The selection of a score as a threshold value for clinical decision-making is based on its associated negative predictive value (NPV), which ranges from 98 to 99% for values in three post-transplant periods: > 2 to < or =6 months, > 6 to < or = 12 months, and > 12 months. Scores below the threshold value rule out ACR, while those above suggest increased ACR risk. Incorporating the AlloMap test into immunomonitoring protocols provides an opportunity for clinicians to enhance patient care and to define its role in immunodiagnostic strategies to optimize the clinical outcomes of heart transplant recipients. This summary highlights the concepts presented in an invited presentation at a conference focused on Immunodiagnostics and Immunomonitoring: From Research to Clinic, in San Diego, CA on November 7, 2006.
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Abstract
The use of routine endomyocardial biopsies post-heart transplant in children remains controversial. It is generally accepted as the gold standard for detecting rejection, but details of the surveillance protocol, such as number and timing of biopsies, remain uncertain, with suggestions that recent advances in immunosuppressant therapy have obviated the need to perform surveillance biopsies. We retrospectively analysed results of endomyocardial biopsies performed in our unit since the introduction of a policy of three routine biopsies in the first six months post-transplantation. We specifically examined only routine surveillance biopsies in order to determine whether clinically unsuspected cases of rejection were identified. Between January 2002 and April 2006, 63 children completed three biopsies in the first six months post-transplant. Of 189 surveillance endomyocardial biopsies, 19 (10%) patients showed significant, grade III or above, rejection. One patient had two episodes of rejection. In only one case the child was haemodynamically unstable, four cases were mildly unwell, and 14 of 19 (74%) cases demonstrated no cardiac symptoms. Four of eight cases treated with sirolimus for some part of their post-transplant course had an episode of rejection and of 54 tacrolimus-treated patients, 13 had an episode of asymptomatic rejection detected. One of the seven infants had significant episode of rejection. Asymptomatic, clinically significant rejection is detected in about 10% of biopsies overall using a three-biopsy protocol in the first six months after paediatric heart transplantation, and occurs in 24% of tacrolimus-treated patients. More frequent surveillance appears needed in children treated with sirolimus, but less frequent surveillance may be possible in infants.
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Affiliation(s)
- Viktoria Dixon
- Department of Paediatric Cardiology, Great Ormond Street Hospital, London, UK
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Kilo J, Laufer G, Antretter H. Endomyocardial biopsy - jugular/subclavian vein approach. Multimed Man Cardiothorac Surg 2006; 2006:mmcts.2005.001149. [PMID: 24413457 DOI: 10.1510/mmcts.2005.001149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endomyocardial biopsy (EMB) is a diagnostic procedure mainly to survey the sufficiency of immunosuppressive therapy after cardiac transplantation. Other indications for EMB remain controversial. After insertion of an introducer sheet in Seldinger's technique, four to six biopsies are taken from the right ventricle by fluoroscopic guidance. EMB is a very safe operation with a low complication rate which can be rapidly performed with little inconvenience for the patient if performed by a skilled surgeon.
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Affiliation(s)
- Juliane Kilo
- Department of Cardiac Surgery, Medical University Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
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Higgins R, Kirklin JK, Brown RN, Rayburn BK, Wagoner L, Oren R, Miller L, Flattery M, Bourge RC. To induce or not to induce: Do patients at greatest risk for fatal rejection benefit from cytolytic induction therapy? J Heart Lung Transplant 2005; 24:392-400. [PMID: 15797738 DOI: 10.1016/j.healun.2004.01.002] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2003] [Revised: 01/03/2004] [Accepted: 01/08/2004] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Induction immunosuppression utilizing lymphocytolytic agents in the early peri-operative period has a number of theoretical and practical advantages and disadvantages. However, the efficacy of cytolytic agents as induction therapy remains unproven. METHODS To assess the current impact of induction therapy in heart transplantation, we queried a multi-institutional database regarding the frequency of use, type of agent, duration of therapy and outcomes of 6,553 patients transplanted from 1990 to 2001. A study group of 5,897 patients were identified who survived the first 48 hours post-transplant and received either no induction therapy (n = 4,161) or induction with OKT3 or anti-thymocyte preparations (n = 1,736). RESULTS By multivariate analysis, risk factors for rejection death were identified and then applied to a model of overall mortality. Among patients with a 1-year risk of rejection death at >5%, induction therapy provided a survival advantage, but survival with induction was decreased when the risk of rejection death was <2%. Specific patient sub-sets that received a survival benefit in the current era with induction included younger patients of black race with >/=4 HLA mismatches and long-term (>6 months) support on a ventricular assist device (VAD). CONCLUSIONS Use and application of induction therapy continues to be controversial in heart transplantation. At present, this approach appears to be beneficial in selected patients who are at high risk for rejection death, but likely detrimental in patients who are at low risk for rejection death. Those with a combination of longer term VAD support, of black ethnicity, and having extensive HLA mismatching are most likely to benefit from cytolytic induction therapy.
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Affiliation(s)
- R Higgins
- University of Alabama at Birmingham, Division of Cardiothoracic Surgery, Birmingham, Alabama 35294, USA
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Butler J, McCoin NS, Feurer ID, Speroff T, Davis SF, Chomsky DB, Wilson JR, Merrill WH, Drinkwater DC, Pierson RN, Pinson CW. Modeling the effects of functional performance and post-transplant comorbidities on health-related quality of life after heart transplantation. J Heart Lung Transplant 2003; 22:1149-56. [PMID: 14550825 DOI: 10.1016/s1053-2498(02)01188-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Health-related quality of life and functional performance are important outcome measures following heart transplantation. This study investigates the impact of pre-transplant functional performance and post-transplant rejection episodes, obesity and osteopenia on post-transplant health-related quality of life and functional performance. METHODS Functional performance and health-related quality of life were measured in 70 adult heart transplant recipients. A composite health-related quality of life outcome measure was computed via principal component analysis. Iterative, multiple regression-based path analysis was used to develop an integrated model of variables that affect post-transplant functional performance and health-related quality of life. RESULTS Functional performance, as measured by the Karnofsky scale, improved markedly during the first 6 months post-transplant and was then sustained for up to 3 years. Rejection Grade > or =2 was negatively associated with health-related quality of life, measured by Short Form-36 and reversed Psychosocial Adjustment to Illness Scale scores. Patients with osteopenia had lower Short Form-36 physical scores and obese patients had lower functional performance. Path analysis demonstrated a negative direct effect of obesity (beta = - 0.28, p < 0.05) on post-transplant functional performance. Post-transplant functional performance had a positive direct effect on the health-related quality of life composite score (beta = 0.48, p < 0.001), and prior rejection episodes grade > or =2 had a negative direct effect on this measure (beta = -0.29, p < 0.05). Either directly or through effects mediated by functional performance, moderate-to-severe rejection, obesity and osteopenia negatively impact health-related quality of life. These findings indicate that efforts should be made to devise immunosuppressive regimens that reduce the incidence of acute rejection, weight gain and osteopenia after heart transplantation.
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Affiliation(s)
- Javed Butler
- Transplant Center, Division of Cardiovascular Diseases, 383 PRB, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.
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Klingenberg R, Koch A, Schnabel PA, Zimmermann R, Sack FU, Haass M, Dengler TJ. Allograft rejection of ISHLT grade >/=3A occurring late after heart transplantation--a distinct entity? J Heart Lung Transplant 2003; 22:1005-13. [PMID: 12957610 DOI: 10.1016/s1053-2498(02)01154-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The significance of International Society of Heart and Lung Transplantation (ISHLT) grade >/=3A rejection detected by routine endomyocardial biopsies beyond 2 years post-transplant remains uncertain. METHODS We performed a retrospective analysis of our single-institution database consisting of 4,041 biopsies (188 patients) from 1986 to 2001. Incidence, clinical correlates and outcome of ISHLT grade >/=3A rejection beyond 2 years post-transplant were analyzed. RESULTS A total of 307 ISHLT grade >/=3A rejection episodes was diagnosed up to 10 years after transplantation, 69 of which occurred later than 2 years post-transplant in 33 of 139 patients ("late rejection") at therapeutic levels of immunosuppression. Late rejection was only marginally correlated with the incidence of moderate rejection within the first 2 post-transplant years (p = 0.09). The incidence of moderate rejection per patient-year decreased from 1.05 in Year 1 over 0.11 in Year 5 to 0.04 in Year 10. The technical failure rate of biopsies remained low throughout the post-transplant period (range 0.7% to 2.4%). Spontaneous resolution of ISHLT grade >/=3A rejection beyond 2 years post-transplant occurred in all 17 patients in whom specific anti-rejection therapy had been electively withheld. Mortality beyond 2 years post-transplant was lower (p = 0.033) in the "late rejecting" group (n = 33) than in the control group (n = 106). CONCLUSIONS Endomyocardial biopsy continues to detect episodes of moderate rejection even very late after heart transplantation, without a close correlation with the rejection frequency in the early post-transplant period. Even without specific treatment, late rejection carries a benign clinical prognosis and may represent a separate biologic entity. Potential long-term effects-for instance, on the pathogenesis of transplant vasculopathy-need further elucidation.
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Affiliation(s)
- Roland Klingenberg
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany
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Abstract
UNLABELLED Histologically proven, moderate acute rejection after orthotopic heart transplantation (OHT) is commonly treated with intravenous steroids. This regimen may result in severe metabolic and infectious side-effects. The purpose of this study was to assess and compare outcomes in treated (T) versus not treated (N-T) biopsy proven 3A rejection episodes in cardiac transplant recipients. METHODS A retrospective analysis was conducted to identify all biopsy proven 3A rejection episodes that occurred over the time period 1995-2000 in patients (patients) >or= 6 months after OHT (n=48 episodes in 35 patients). Of the 48 episodes, 19 were N-T and 29 were T. Decision to treat 3A rejection was based on time after transplant, haemodynamic and/or clinical compromise and left ventricular (LV) dysfunction measured by 2D echo. Most N-T episodes received an increase in background immunotherapy. RESULTS Time from transplant to index 3A episode in N-T patients was 4.2 versus 2.7 yr for the T patients (p=0.06). There were no differences seen between T and N-T groups for the first and second post-3A biopsy results or LV function post-3A. Presence of coronary disease or death were not different between groups. Of the 29 patients with T episodes, no differences in outcomes (death, first and second post-3A biopsy score, coronary disease, myocardial infarction, or LV function) were seen based on use of treatment with intravenous versus oral steroid. CONCLUSION In patients more than 6 month after OHT, there were no differences in outcomes (ongoing rejection or LV function) between N-T episodes of 3A rejection and T episodes. In T patients the use of oral steroids was equally as effective for treatment of 3A episodes as intravenous steroids.
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Affiliation(s)
- D H Delgado
- Division of Cardiology and Heart Transplant, Toronto General Hospital, Toronto, Ont., Canada
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Gribbin GM, Gilbertson JA, Hawkins PN. Diagnosis of amyloidosis by histological examination of subcutaneous fat sampled at the time of pacemaker implantation. Heart 2002; 87:e7. [PMID: 12010955 PMCID: PMC1767123 DOI: 10.1136/heart.87.6.e7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Atrioventricular conduction disease may occur in a range of conditions. If echocardiography suggests the presence of an infiltrative cardiomyopathy the diagnosis of amyloidosis may be confirmed by subcutaneous fat sampling from the site of pacemaker implantation. This technique requires no additional invasive procedure and confers no extra risk for the patient. Confirmation of amyloidosis provides important prognostic information and may allow specific treatment.
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Affiliation(s)
- G M Gribbin
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK.
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Cantin B, Giannetti N, Parekh H, Panchal SN, Kwok BWK, Najem R, Woodman K, Hunt SA, Valantine HA. Mycophenolic acid concentrations in long-term heart transplant patients: relationship with calcineurin antagonists and acute rejection. Clin Transplant 2002; 16:196-201. [PMID: 12010143 DOI: 10.1034/j.1399-0012.2002.01122.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND When used in conjunction with steroids and cyclosporin, mycophenolate mofetil (MMF) has been shown to significantly reduce mortality and incidence of rejection in the first year after heart transplantation. It also appears that in this early post-transplantation period, the monitoring of immunosuppressive therapies may be warranted. The current study was undertaken to determine if such monitoring is still useful more than 1 yr after heart transplantation. METHODS Twenty-six patients who had survived the first year after orthotopic heart transplantation and had been on MMF therapy for more than 3 months were prospectively followed. At the time of their routine endomyocardial biopsy blood samples were taken to monitor immunosuppressive therapy. Most patients had two samples taken, on average 109 d apart. RESULTS There were 22 episodes of asymptomatic rejection documented on a total of 48 biopsies. Of these, only two were of ISHLT (International Society for Heart and Lung Transplantation) grade 3A the remainder being of ISHLT grades 1 or 2. There was no relation between immunosuppressive regimen (tacrolimus and MMF or cyclosporin and MMF) and rejection. There was no relation between monitored immunosuppressive levels and rejection. Patients with the combination of MMF and tacrolimus had significantly higher plasma mycophenolic acid levels despite significantly lower daily MMF dose. CONCLUSION There does not appear to be a benefit in continued monitoring of plasma mycophenolic acid levels beyond the first year of heart transplantation. There were significant differences in plasma mycophenolic acid levels depending on the type of calcineurin inhibitor concomitantly used.
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Affiliation(s)
- Bernard Cantin
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
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