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Abstract: Small cell carcinoma (SCC) in the head and neck region is an extremely rare high-grade malignant tumor. The authors report a case of an SCC occurring in the left buccal region. An 85-year-old man exhibited left cheek swelling that rapidly increased in size. Histopathological examination revealed invasive growth of an SCC into the musculo-adipose tissue. Immunohistochemically, the tumor cells were positive for cytokeratin (AE1/AE3), neuron-specific enolase (NSE) and CD56, but negative for cytokeratin 20. The patient received chemotherapy and radiotherapy, which resulted in marked regression of the tumor. Surgical resection was performed. The serum levels of NSE and pro-gastrin-releasing peptide (pro-GRP) increased and multiple metastases of the tumor occurred 1 month after surgery. SCCs tend to exhibit aggressive invasion and metastasis so chemotherapy for the whole body is recommended to prevent dissemination of the tumor cells. Serum levels of NSE and pro-GRP are considered to be useful tumor markers for understanding the status of the tumor and the clinical symptoms. [Copyright &y& Elsevier]

Abstract: This longitudinal study evaluated the outcomes of secondary autogenous bone graft combined with platelet-rich plasma (PRP) in the alveolar cleft. Thirty-five alveolar clefts in 30 patients with grafted autogenous bone and PRP (PRP group), and 36 clefts in 30 patients with grafted autogenous bone alone (non-PRP group) were enrolled. PRP was extracted from autogenous blood using a plasma centrifuge system (SmartPReP SMP-1000). The density and resorption of grafted bone were evaluated at 1 week, and 1, 3, 6 and 12 months postoperatively. Bone density was quantitatively assessed as an aluminum-equivalence (Al-Eq) value. Moreover, relationships between bone resorption rate and prognostic factors were discussed. Al-Eq values decreased significantly until 3 months, and then increased up to 12 months in both groups. The Al-Eq rate in the PRP group was significantly smaller than that in the non-PRP group at 3 months. No significant differences were observed in the bone resorption rate between the groups. Regarding prognostic factors, continuous mechanical stress affected bone resorption with or without PRP. The authors suggest that PRP may enhance bone remodeling in the early phase, however, PRP seems to be insufficient as a countermeasure against bone resorption following secondary bone graft in the long term. [Copyright &y& Elsevier]

PURPOSE: To 3-dimensionally analyze outcomes after the secondary treatment of bilateral cleft lip-nose deformity at the Department of Oral and Maxillofacial Surgery, Kagoshima University Hospital, Kagoshima, Japan. PATIENTS AND METHODS: Ten Japanese male young adults with bilateral cleft lip with or without palate (BCL±P) who had undergone definitive nose correction and were followed up for 1 to 4 years were enrolled in this study. Ten unaffected race- and gender-matched young adults were used as controls. All patients underwent secondary correction of the nose by open rhinoplasty through a bilateral reverse-U incision, columellar strut graft, and medial-upward advancement of the nasolabial components with vestibular expansion by use of a free mucosal graft. In 3 patients with an extremely short columella, an inferiorly based small pedicle flap from rim skin rotated into the columellar base was added for columella lengthening. Nasal forms were periodically measured by use of a 3-dimensional noncontact laser scanner. The angular and linear measurements and the curvature of the alar groove arch were compared between patients and control subjects. RESULTS: Comparison of the preoperative and postoperative nasal forms showed significant improvements in the nasal dorsum and tip angles, as well as nasal height. The size of the nasal alar grooves was also increased to the same size range as the control subjects. There were persistent differences between postoperative columellar angle and nasal width in patients and those in the control subjects. CONCLUSIONS: Our surgical procedures can provide an acceptably protruded nasal form for patients with BCL±P without damaging the upper lip tissue, but further improvement to prevent nasal tip overprojection may be useful. [ABSTRACT FROM AUTHOR]

Burn-up characteristics of accelerator-driven system, ADS has been evaluated utilizing the fuel composition from MOX PWRs spent fuel. The system consists of a high intensity proton beam accelerator, spallation target, and sub-critical reactor core. The liquid lead–bismuth, Pb–Bi, as spallation target, was put in the center of the core region. The general approach was conducted throughout the nitride fuel that allows the utilities to choose the strategy for destroying or minimizing the most dangerous high level wastes in a fast neutron spectrum. The fuel introduced surrounding the target region was the same with the composition of MOX from 33 GWd/t PWRs spent-fuel with 5 year cooling and has been compared with the fuel composition from 45 and 60 GWd/t PWRs spent-fuel with the same cooling time. The basic characteristics of the system such as burn-up reactivity swing, power density, neutron fluxes distribution, and nuclides densities were obtained from the results of the neutronics and burn-up analyses using ATRAS computer code of the Japan Atomic Energy research Institute, JAERI. [Copyright &y& Elsevier]

The impact of cardiac rehabilitation after heart transplantation on patient reported outcomes (PROs) has not been well validated. We performed a prospective anonymized survey focusing on PROs of those who survived more than one year after heart transplantation who received or did not receive cardiac rehabilitation. Between December 2016 to March 2020, patients over 18 years old and who survived more than one year after heart transplantation were consented and enrolled in a prospective survey study. Patients were divided into those that received CR (n=131) and those that did not receive CR (n=96). PROs which were derived from the previously validated SF-36 and KCCQ-12. To ensure anonymity for the sensitive questions, the survey was conducted in a separate area with the web-based system using a tablet computer. 264 patients consented during the study period, and 227 (86.0%) completed the survey. Patients who participated in a first-year CR program had improved social activity limitation (-2.82 vs. -2.43, p=0.040) and happiness in the interests or hobbies (1.60 vs. 0.97, p=0.040) (Figure). In both groups, patients reported improvement in shortness of breath, fatigue, nervousness, sleep disturbance, relaxation, good spirits, difficulty in concentration (Figure). In anonymized patient-reported outcomes, cardiac rehabilitation appears to improve quality of life after heart transplantation and should be encouraged. [ABSTRACT FROM AUTHOR]

Mycophenolate mofetil (MMF) is an anti-proliferative agent that is used in heart transplantation (HTx). The multicenter randomized trial of mycophenolate published in Transplantation in 1998 demonstrated that MMF had a survival benefit. The average dose of MMF was 2.8 g/day. It is not clear whether lower doses of MMF also have benefit in terms of control of rejection as well as other outcomes. Between 2010 and 2018, we assessed 240 HTx patients and divided them into categories of MMF dosing in the first year after HTx. The average daily dose of MMF was obtained for all patients in the first year, with an average of 10 MMF dose levels obtained over the first year. Patients were divided into groups based on receiving an average daily dose of <500 mg MMF/day, 500-1000 mg/day, 1001-1500 mg/day, 1501-2000 mg/day, and >2000 mg/day. Endpoints included 1-year survival, 1-year freedom from cardiac allograft vasculopathy (CAV), 1-year freedom from non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, percutaneous coronary intervention/angioplasty, new congestive heart failure, pacemaker/implantable cardioverter-defibrillator placement, and stroke), and 1-year freedom from rejection (any treated rejection (ATR), acute cellular rejection (ACR), antibody mediated rejection (AMR)). Patients treated with <500 mg MMF/day and >2000 mg MMF/day had a trend toward decreased freedom from ATR. There was no difference in outcome between all groups in terms of 1-year survival, freedom from CAV, freedom from NF-MACE, and freedom from ACR and AMR. The average daily dose of MMF in the first year after HTx does not appear to have an impact on outcome. Longer follow-up will be necessary to assess whether MMF dosing correlates to long-term complications such as CAV. Larger number of patients will be needed to confirm these findings. [ABSTRACT FROM AUTHOR]

In the past, Hepatitis B donors have been declined in patients who have not been vaccinated by the Hepatitis B vaccine. There is concern that these donors would transmit Hepatitis B to the recipient if they are not vaccinated. There is treatment available for these Hepatitis B infections, however, it has not been established as to its efficacy in patients on immunosuppression. In addition, hepatitis viruses have been reported to affect the endothelium of vital organs. Hepatitis B may injure the endothelium of the coronary vascular tree and could potentially result in a greater development of cardiac allograft vasculopathy (CAV) after heart transplantation. Therefore, we sought to assess this possibility by examining our patients who received Hepatitis B donors. Between 2010 and 2016 we assessed 24 heart transplant patients who received a Hepatitis B donor. All of the recipients had received a Hepatitis B vaccine prior to transplantation. Endpoints include 3-year survival, 3-year freedom from CAV, 3-year freedom from non-fatal major adverse cardiac events (NF-MACE), and freedom from first year rejection, including any treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR). These study patients were compared with 600 patients without Hepatitis B donors in a contemporaneous era. 3-year survival, freedom from NF-MACE, and freedom from first year rejection were similar between the Hepatitis B and control groups. There is numerically a lower incidence of freedom from CAV in the Hepatitis B group compared to the control, but this was not statistically significant. Hepatitis B donors appear to have acceptable outcome compared to non-Hepatitis B donors after heart transplantation. Larger numbers of Hepatitis B donors will be needed to assess risk for increased CAV development. [ABSTRACT FROM AUTHOR]

Sensitized patients have prolonged wait times for heart transplant and often low-level donor specific antibodies (DSA) will be crossed when accepting a donor heart. The purpose of this study was to determine if positive low-level DSA at the time of transplant increase in strength post transplant and increase the risk of antibody mediated rejection (AMR). We reviewed 72 heart transplant patients between 2010 and 2018 in whom low-level DSA were crossed. DSA strength, as measured by mean fluorescence intensity (MFI) and AMR on biopsy was assessed at 1, 3, 6, 12 months post transplant. Other outcomes assessed: freedom from first-year rejection (acute cellular rejection (ACR), any treated rejection (ATR)), freedom from cardiac allograft vasculopathy (CAV, as defined by stenosis ≥30% by angiography), and freedom from graft dysfunction (LVEF ≤40%). Patients were compared to a contemporaneous control group conditional to 1-year survival without DSA at transplant. Approximately one-third of patients with pre-existing DSA at transplant demonstrated an increase in DSA strength. Patients with pre-existing DSA had decreased freedom from ATR and AMR but no differences in freedom from CAV, graft dysfunction, or ACR compared to the control group. Crossing low-level DSA may increase the risk of AMR, but there is no difference in clinically important sequelae such as CAV or graft dysfunction. Thus, accepting low-level DSA at the time of transplant appears feasible and could broaden the donor pool. [ABSTRACT FROM AUTHOR]

Collagen vascular disease, including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and scleroderma (SSc), all have auto-antibodies in their pathogenesis though the effect after heart transplantation is not known. Our aim was to assess the impact of collagen vascular disease on the risk of post-transplant donor specific antibodies (DSA), rejection, and cardiac allograft vasculopathy (CAV). The 22 pts transplanted 2010-2018 with collagen vascular disease: SLE (n=7), RA (n=9), SSc (n=3), and mixed (n=3) were compared to 772 pts with no collagen vascular disease. All had controlled disease prior to transplant. Outcomes were assessed: 1-year survival, freedom from CAV (stenosis ≥30%), non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, heart failure, percutaneous intervention, defibrillator/pacemaker, stroke), acute cellular rejection (ACR), antibody-mediated rejection (AMR), DSA, and left ventricular dysfunction (ejection fraction <40%). Pts with pre-transplant collagen vascular disease had lower freedom from CAV (77.3% vs 95.4%, p<0.001). Other outcomes were similar between study and control groups. There were no differences in outcomes in collagen vascular disease pts with and without pre-transplant disease-modifying agents. Patients with pre-transplant collagen vascular disease have increased risk of CAV. The mechanism is not clear, but adjustments in immunosuppression and surveillance may be warranted post heart transplantation. [ABSTRACT FROM AUTHOR]

The development of post-transplant donor specific antibody (DSA), especially those that bind complement (C1q+), has been associated with development of cardiac allograft vasculopathy (CAV). Our strategy is to employ densitization for patients with DSA and cardiac dysfunction and/or C1q+. The purpose of this study was to assess the response of C1q+ DSA to desensitization therapy. We reviewed 43 heart transplant pts between 2010 and 2018 who developed DSA and received post-transplant desensitization with IVIG/rituximab and/or plasmapheresis/bortezomib. There were 25 pts with C1q+ DSA and 18 pts with cardiac dysfunction and DSA; 20 had C1q DSA and cardiac dysfunction. Reponse was defined by antibody binding of the immunodominant DSA (highest mean fluorescence intensity (MFI)) by Luminex neat assay 6 months post therapy. Response was compared between pts with C1q+ vs C1q- DSA and pts with and without cardiac dysfunction. The effect of desensitization cardiac function was also assessed. Pts with C1q+ DSA appear to have a similar response to desensitization therapy in terms of decreased immunodominant MFI after therapy compared to C1q- DSA. DSA with and without cardiac dysfunction also appear to have similar response to therapy. In pts with DSA with cardiac dysfunction, 75.0% (15/20 pts) had improved cardiac function following therapy. A majority of transplant pts with DSA with/without C1q+ or with/without cardiac dysfunction did respond to desensitization therapy, however it is not clear whether this treatment would lead to a decrease in CAV. Long term follow up and larger number of pts will be needed to answer this question. [ABSTRACT FROM AUTHOR]

Anti-thymocyte globulin (ATG) has been used as an induction agent in heart transplant (HTx). Early studies suggest that ATG can decrease de novo donor specific antibody (DSA) production after HTx. It has not been established as to the efficacy of ATG in various levels of sensitized pts undergoing HTx. Between 2010-18, we assessed 370 sensitized pts who were divided into panel reactive antibody (PRA) groups including a control group without sensitization but who received ATG: Group A: 0% (control); Group B: 1-25%; Group C: 26-50%; and Group D: >50%. Pts received ATG immediately post-transplant x5 days. Blood was drawn for antibody detection at baseline, 1, 3, 6, and 12 months after HTx. Groups were assessed for freedom from 1-year survival, rejection (any treated rejection (ATR), acute cellular rejection (ACR), and antibody mediated rejection (AMR)), freedom from non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, percutaneous coronary intervention/angioplasty, new congestive heart failure, pacemaker/implantable cardioverter-defibrillator placement, and stroke), and freedom from cardiac allograft vasculopathy (CAV). Pts in Groups C and D had decreased freedom from DSA compared to the Control. Furthermore, there was lower freedom from AMR in pts in Group D compared to Control. There were no differences in outcome between each Group and the Control in 1-year survival, freedom from CAV, freedom from NF-MACE, freedom from any treated rejection, and freedom from ACR (see Table). ATG induction may be beneficial in sensitized patients with PRA under 50% but did not appear to decrease the development of AMR and DSA in those pts with PRA >50% compared to control. Larger studies and longer follow-up will need to be performed to assess ATG's impact on antibodies and the development of chronic rejection (CAV). [ABSTRACT FROM AUTHOR]

Severe primary graft dysfunction (PGD) is seen in approximately 5% of all heart transplant recipients per the International Society for Heart and Lung Transplantation (ISHLT) PGD grading scale. These patients suffer endothelial cell damage and are known to have increased risk of early mortality. It is not known whether the survivors of severe PGD develop more donor specific antibody (DSA), have more treated rejections, have increased risk of the development of cardiac allograft vasculopathy (CAV), and have increased mortality at 3 years post transplantation. We sought to assess this potential association. Between 2010-2016 we assessed 24 heart transplant patients who developed severe PGD per the ISHLT PGD grading scale. These patients who developed severe PGD were compared to those without severe PGD in a contemporaneous era. Patients were then followed for 3 years and assessed for the following endpoints: 3-year survival, 3-year freedom from CAV, 3-year freedom from non-fatal major adverse cardiac events (NF-MACE, defined as myocardial infarction, percutaneous coronary intervention/angioplasty, new congestive heart failure, pacemaker/implantable cardioverter-defibrillator placement, and stroke), and 1-year freedom from rejection, including any treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR). Patients with severe PGD had decreased 3-year survival, 1-year freedom from any treated rejection, and 3-year freedom from NF-MACE compared to those patients who did not have severe PGD. There were no significant differences between the two groups in terms of 3-year freedom from CAV and freedom from DSA. Severe PGD appears to have increased mortality and morbidity with more rejection and more NF-MACE. More intense therapies to offset the inflammatory response from severe PGD should be pursued. [ABSTRACT FROM AUTHOR]

Primary graft dysfunction (PGD) is observed in approximately 7% of all heart transplant (HTx) patients (pts). According to the International Society for Heart and Lung Transplantation (ISHLT), a new PGD scale includes left ventricular (PGD-LV), or right ventricular (PGD-RV). PGD-LV when severe is noted to have increased mortality. PGD-RV has been described as hemodynamics with RAP >15 mmHg, PCWP <15 mmHg, CI < 2.0 L/min/m2, or need for RV temporary support. PGD-RV has not been well studied. Between Dec 2013 and Dec 2018, we assessed 13 HTx pts who developed PGD-RV within 24 hours after HTx and compared them to pts without PGD. Endpoints included 1-year survival, need for temporary kidney dialysis, need for RV unloading with sildenafil, first year rejection including any treated rejection (ATR), 1-year freedom from cardiac allograft vasculopathy (CAV), and 1-year freedom from non-fatal major adverse cardiac events (NF-MACE, defined as myocardial infarction, percutaneous coronary intervention/angioplasty, new congestive heart failure, pacemaker/implantable cardioverter-defibrillator placement, and stroke). Pts with PGD-RV compared to pts without PGD had similar 1-year survival, freedom from CAV, freedom from NF-MACE, and rejection. 90% of pts with PGD-RV required RV unloading therapy which may have affected outcome. There was a trend for a lower freedom from temporary kidney dialysis in the PGD-RV group. PGD-RV after HTx appears to have acceptable outcome with good recovery. RV unloading therapy may be helpful. However, there was an associated increased need for temporary kidney dialysis within the first year after HTx. Larger numbers are warranted to confirm these findings. [ABSTRACT FROM AUTHOR]

Sensitized patients awaiting heart transplantation (HTx) are at increased risk for mortality as their waitlist time is lengthened due to incompatible donors and a subsequently narrowed donor pool. Therefore, these patients undergo desensitization therapies to lower circulating antibodies and to restore the donor pool for these patients. These patients subsequently undergo HTx; however it has not been well established as to their longer-term outcome following HTx. Between 2010 and 2014 we assessed 42 patients awaiting HTx who were sensitized (average cPRA 84%) and subsequently underwent desensitization therapy prior to HTx. These patients then underwent HTx and were followed for 5-year outcome. Endpoints post-HTx included 5-year survival, 5-year freedom from cardiac allograft vasculopathy (CAV), 5-year freedom from non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, percutaneous coronary intervention/angioplasty, new congestive heart failure, pacemaker/implantable cardioverter-defibrillator placement, stroke), and 1-year freedom from rejection (any treated rejection (ATR), acute cellular rejection (ACR), antibody mediated rejection (AMR)). Patients were compared to a contemporaneous group of HTx patients that did not receive desensitization therapy prior to HTx conditional to 1-year survival (n=329) for the same endpoints. Sensitized patients that received desensitization therapy prior to HTx had significantly lower freedom from AMR. There is a trend for increased freedom from NF-MACE in this desensitized group. There were no differences between the two groups in terms of survival, freedom from CAV, and freedom from ACR. Sensitized patients awaiting HTx who undergo desensitization therapy appear to have decreased freedom from first-year AMR. However, these patients appear to have comparable outcome (ie survival and CAV) at 5-years post-HTx to HTx patients that do not undergo desensitization therapy. [ABSTRACT FROM AUTHOR]

A large number of heart transplant patients are weaned off corticosteroids within the first year after heart transplantation. These patients are selected as they do not have rejection or graft dysfunction. In addition, these patients have not developed donor-specific antibodies (DSAs) and therefore are viewed as being immune-privileged. However, it has not been well established whether these patients have enhanced 5-year outcome compared to patients who remain on prednisone. Between 2010 and 2014, we assessed 292 heart transplant patients who were successfully weaned off prednisone. These patients were compared to a contemporaneous cohort (n=173) of patients who had not undergone steroid weaning. Patients who were initiated on steroid weaning but failed were excluded. Endpoints include 5-year survival, 5-year freedom from cardiac allograft vasculopathy (CAV, stenosis ≥30% by angiography), 5-year freedom from non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke), 5-year freedom from left ventricular dysfunction (LVEF ≤40%) or infection, and 1-year freedom from any treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR). Patients who were successfully weaned off prednisone had significantly greater freedom from 1-year any treated rejection and 5-year freedom from left ventricular dysfunction. Those weaned off prednisone had comparable survival, freedom from CAV, NF-MACE, and infection to those not weaned off corticosteroids. Steroid weaning is associated with long-term maintenance of normal cardiac function and may indeed represent an immune-privileged state. There does not appear to be any notable shortcoming to steroid weaning. [ABSTRACT FROM AUTHOR]

The development of donor specific antibody (DSA) after heart transplantation has been associated with increased development of cardiac allograft vasculopathy (CAV). Steroid weaning has been popular among heart transplant programs, however, it is not known whether steroid free regimens present an increased risk of the development of DSA. Therefore, we sought to address this question. Between 2010 and 2013 we assessed 229 heart transplantation patients who survived the first year after heart transplantation. Patients were divided into those that were maintained on prednisone (n=120) and those that were weaned off (n=109) at 1-year post-transplant. Subsequent freedom from DSA in the ensuing 5 years was then assessed between these two groups. In addition, we assessed 5-year subsequent outcomes of survival, freedom from CAV, freedom from non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke), and 1-year freedom from rejection (any treated rejection (ATR), acute cellular rejection (ACR), antibody-mediated rejection (AMR)). There were no significant difference between the two groups in subsequent 5-year freedom from DSA, survival, freedom from NF-MACE, and freedom from rejection. Weaning of corticosteroids from maintenance after heart transplantation does not appear to increase risk for the development of DSA or other clinical longer-term outcomes. The ability to wean corticosteroids in individual patients after transplant may represent an immune-privileged state. [ABSTRACT FROM AUTHOR]

Combined heart and kidney transplant has a protective effect on the cardiac graft. We set out to assess the impact of donor, recipient and transplant characteristics on post-transplant renal graft function. We evaluated combined heart-kidney transplant recipients at a single high volume transplant center between March 2012 and December 2017. Recipients with primary cardiac graft dysfunction were excluded. The primary outcome was delayed renal graft function (DRGF) as defined by need for dialysis within the first week of transplantation. The secondary outcome was any dialysis requirement within the first year. A univariate logistic regression model was used to assess the association between the donor, recipient and transplant factors with the primary and secondary outcomes. We identified 66 combined heart-kidney transplant recipients for analysis. Elevated recipient creatinine prior to transplant was associated with DRGF (OR 1.80, 95% 1.25-2.59, p = 0.002). The remainder of evaluated donor and recipient factors were otherwise not associated with acute renal dysfunction (Table 1). Elevated pre-transplant creatinine (OR 1.73, 95% 1.21-2.50, p = 0.003) and redo transplantation (OR 5.70, 95% 1.05-30.87, p = 0.043) were associated with needing dialysis within the first year after transplant (Table 2). In our high volume single center experience of combined heart and kidney transplantation, recipient creatinine prior to transplant was the biggest predictor of primary renal graft failure. In addition, redo heart transplantation increases risk of dialysis within the first year. [ABSTRACT FROM AUTHOR]

Sensitization occurs with blood transfusions in recipients of left ventricular assist device (LVAD). 30% of LVAD patients develop a panel reactive antibody (PRA) screen of >= 10%. Highly sensitized patients have an increased morbidity and mortality after heart transplantation. Desensitization therapy is considered for patients with PRAs> 50%. Below are the results of desensitization therapies in mechanical circulatory support (MCS) patients. From 2010-2016, 49 MCS patients who underwent desensitization therapy were compared to a control group who underwent desensitization but did not have MCS support. Desensitization therapy used in both groups included combinations of rituximab/IVIG and plasmapheresis/bortezomib. Baseline PRAs prior to desensitization were repeated 2-4 weeks after treatment. For patients who underwent heart transplantation, outcomes included 1-year survival, freedom from cardiac allograft vasculopathy (CAV), freedom from non-fatal major adverse cardiac events (NF-MACE, defined as myocardial infarction, percutaneous coronary intervention, new congestive heart failure, pacemaker/implantable cardioverter-defibrillator placement, and stroke), and freedom from any treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR). Desensitization therapy was successful in both MCS and control groups, resulting in an average of 12% decrease in PRA. When subgrouped into Class 1 versus Class 2 antibodies, Class 1 antibodies appeared to have a better response after desensitization therapy (PRA decrease of 15% in Class 1 versus a decrease of 9% in Class 2). Patients on MCS support appear to have a numerical lower incidence of AMR with comparable first-year survival, freedom from CAV, NF-MACE, ATR, and ACR. Desensitization of MCS patients appeared to be beneficial. Removal of the MCS device at the time of transplant may be a factor in potentially less AMR post-transplant. [ABSTRACT FROM AUTHOR]

Patients with end-stage heart failure may undergo mechanical circulatory support (MCS) as a bridge to transplant. This strategy may be complicated by sensitization due to blood transfusions as well as driveline infections. As sensitization narrows the donor pool, desensitization may be performed. The purpose of this study was to determine the impact of desensitization therapy on infections in MCS patients with an existing driveline infection. We reviewed 45 MCS patients who developed a driveline infection between 2012-2018. Patients were divided into: sensitized (PRA >10%, n=22) and not sensitized (n=23). Sensitized patients were divided into: desensitization (when CPRA > 50%; n=7) and no desensitization (n=15). Desensitization included IVIG, rituximab, bortezomib and/or plasmapheresis. Outcomes were assessed 1 year after the driveline infection: survival, freedom from readmission, freedom from new driveline infection, and freedom from any infection. There was no difference between sensitized and non-sensitized MCS patients with a driveline infection in 1-year survival, freedom from readmissions, or freedom from any subsequent infection. There was no difference in outcomes between sensitized patients who received desensitization therapy and those who did not. Desensitization appears to be safe in MCS patients with an existing driveline infection to potentially expand the compatible donor pool. [ABSTRACT FROM AUTHOR]

Increased perioperative risk has been observed in patients with left ventricular assist devices (LVAD) and total artificial hearts (TAH) undergoing heart transplantation with worse outcomes in TAH patients. The purpose of this study was to review perioperative transplant outcomes in TAH vs LVAD patients at a high-volume transplant center. We reviewed perioperative transplant outcomes of 46 TAH patients and 85 LVAD patients from 2010-2018. Outcomes included perioperative transfusions (units of packed red blood cells, fresh frozen plasma, platelets, cryoprecipitate), time in the operating room (OR), intensive care unit (ICU) days immediately post-transplant, freedom from return to OR for bleeding, freedom from primary graft dysfunction (PGD), and 1-year freedom from temporary dialysis. In addition, 1-year outcomes included survival, freedom from cardiac allograft vasculopathy (CAV), freedom from non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, heart failure, percutaneous intervention, defibrillator/pacemaker implant, stroke), and freedom from first-year rejection (any treated rejection (ATR), acute cellular rejection (ACR), antibody-mediated rejection (AMR)). TAH patients had more perioperative blood transfusions, and had decreased freedom from return to the OR for bleeding, temporary dialysis, and NF-MACE. There were no differences between groups in the time in OR, ICU days post-transplant, and freedom from PGD, survival, CAV, and rejection. TAH patients appear to have increased perioperative post-transplant risk for some parameters though no difference in PGD or survival compared to LVAD patients. In a high volume center, there can be acceptable post-transplant outcomes in TAH patients. [ABSTRACT FROM AUTHOR]

Herpes zoster, otherwise known as shingles, can be a devastating complication after heart transplantation due to persistent and severe herpetic neuralgia. Our heart transplant patients are recommended to have the shingles vaccine prior to heart transplantation, but this is not always achieved. We sought to assess whether the shingles vaccine did indeed prevent clinical shingles development after heart transplantation. Between 2010 and 2018, we assessed 40 heart transplant patients who developed shingles post-transplant. We divided patients into those that received either the Zostavax or Shingrix vaccine at our center before transplant versus those that did not. Endpoints included the severity in terms of general pain level and herpetic neuralgia and the location of the rash. 19 of the 40 patients who developed shingles post-transplant had been vaccinated prior to transplant. Most patients were treated with acyclovir, valacyclovir, or famciclovir. Patients in both groups appear to face a comparable severity of shingles. While patients who received the shingles vaccine developed rashes primarily in the truncal area of the body, patients without the vaccine developed rashes mostly in the truncal area and above the neck. Receiving the shingles vaccine prior to heart transplant does not seem to decrease the clinical development of shingles post-transplant. However, a larger number of patients are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Purpose Certain donor characteristics after heart transplantation (HTx) may have less optimal outcome post-HTx. One factors leading to worse outcome is female donors to male recipient possibly due to size (height and weight) mismatch relative to male donors. We try to compensate for this size mismatch by using obese female donors into male recipients. However, there have been recent concerns with obese donors, in the sense that there are commonly large fat deposits on the donor heart. It is not known whether short and obese female donors (weight oversizing) results in acceptable outcome after HTx. We sought to assess for this possibility in our large single center. Methods Between 2010 and 2017 we assessed 799 HTx patients and divided them into those male recipients who received female donors (n=246) that were short (≤ 66 inches) and obese (BMI≥30) (n=61) and short and non-obese (BMI<30) recipients (n=128). In addition, we compared both groups to a male donor cohort inclusive of similar heights and weights. All patients were reviewed for 1-year outcomes including survival, freedom from CAV (as defined by stenosis ≥ 30% by angiography), freedom from non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke), and freedom from any-treated rejection, acute cellular rejection, and antibody-mediated rejection. Results There is no significant difference in 1-year outcomes between short and obese female donors, short and non-obese female donors, and male donors of similar heights and weights (see tables). Conclusion Short and stout female donors appear to be acceptable for HTx which increases the donor pool. [ABSTRACT FROM AUTHOR]

Purpose Donor left ventricular hypertrophy (LVH) defined as either the interventricular septum (IVS) or posterior wall (PW) > 1.2 cm has been a concern for donor heart acceptance for transplantation. Cardio-pulmonary resuscitation (CPR) with chest compressions may also cause edema within the IVS and PW. It is not clear whether LVH due to a history of hypertension (HTN) in the donor or LVH due to edema from CPR have the same outcome after heart transplantation. Methods Between 2014 and 2017, we assessed 54 heart donors with LVH > 1.2 cm. We divided these donor hearts into those with a history of HTN (n=19) and those without (n=35). Post-operatively, we assessed for the presence of primary graft dysfunction (PGD), 1-year freedom from any-treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR), 1-year freedom from cardiac allograft vasculopathy (CAV) as defined by stenosis ≥ 30% by angiography, and 1-year survival. We also assessed for the persistence of LVH at 6 and 12 months post-transplantation. Results There was no significant difference between LVH donors with and without a history of HTN in PGD, 1-year survival and 1-year freedom from CAV, ATR, ACR and AMR. LVH donors with HTN were older than those without HTN. LVH in donors with and without a history of HTN resulted in similar rates of LVH persistence at 6 and 12 months after transplantation. The persistence of LVH at 1 year was similar between the groups. (see table) Conclusion Donor heart LVH and history of HTN does not increase the risk of poor outcome after heart transplantation. Acceptable survival and resolution of LVH (occurs in most patients) indicates that LVH is well tolerated and may not be a concern in donor heart selection. Larger studies will be needed to confirm these findings. [ABSTRACT FROM AUTHOR]