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Objective Assessing the efficacy of intraoperative 4-factor prothrombin complex concentrate (4F-PCC) use in blood product utilization, time to chest closure, intensive care unit (ICU) and hospital length of stay (LOS), thromboembolic complications, renal injury and mortality in left ventricular assist device (LVAD) patients on home anticoagulation therapy with warfarin, undergoing orthotopic heart transplantation (OHT). Design Retrospective analysis of OHT patients at Tufts Medical Center from May 2013 to October 2016. Setting Single-institution, university hospital setting. Participants Patients with preexisting LVADs who received orthotopic heart transplants (n = 74; 32 patients 4F-PCC, 42 patients no 4F-PCC). Interventions Warfarin reversal using 4F-PCC in patients with LVADs undergoing orthotopic heart transplantation with the 4F-PCC dosing partitioned such that one-third was given pre-CPB and two-thirds were given post-CPB. Measurements and Main Results The 4F-PCC group required less plasma (6 [IQR 4] v 1.31 [IQR 2] U, p < 0.001), cryoprecipitate (10 [IQR 10] v 7.50 [IQR 5] U, p < 0.001), and packed red blood cells (5 [IQR 4] v 2 [IQR 1.5] U, p < 0.001) and had a shorter time to chest closure (618.8 ± 111.4 v 547.9 ± 110.1 minutes, p = 0.008). There was no difference in platelet transfusion (2 [IQR 1] v 2 [IQR 1] U, p = 0.16), ICU or hospital LOS, acute kidney injury, or mortality. No thrombotic complications occurred. Conclusions Replacing plasma with 4F-PCC to reverse preoperative warfarin anticoagulation during OHT was associated with a shorter time to chest closure and less blood product utilization, without an increase in acute kidney injury, thromboembolic complications, or death. [ABSTRACT FROM AUTHOR]

Background There is growing concern regarding the association between pre-transplant amiodarone exposure and post-transplant adverse outcomes. We hypothesized that amiodarone use would be associated with the development of severe primary graft dysfunction (PGD) in a dose-dependent manner. Methods This was a retrospective review of 269 adult orthotopic heart transplantation (OHT) recipients at our institution between 2010 and 2014. At the time of OHT, 100 were receiving amiodarone therapy (Group 1) and 169 were not (Group 2). Results Pre-OHT creatinine was higher in Group 1 (1.49 ± 0.63 vs 1.27 ± 0.68 mg/dl, p = 0.011). At time of listing, Group 1 had higher frequency of status 2 (42.0% vs 29.0%), and Group 2 had higher frequency of status 1A (20.7% vs 8.0%; p = 0.009). Severe PGD (mechanical circulatory support within 24 hours post-OHT) was significantly higher in Group 1 (20.0% vs 5.3%, p < 0.001). Pre-OHT amiodarone use was an independent risk factor for severe PGD (odds ratio [OR], 6.05; 95% confidence interval [CI], 2.47–14.83; p < 0.001) and in-hospital mortality (OR, 2.88; 95% CI, 1.05–7.88; p = 0.039) in multivariable analysis. Each 100-mg increase in the day-of-OHT amiodarone dose (OR, 1.55; 95% CI, 1.26–1.90) and each 18,300-mg increase in the 6-month cumulative dose (OR, 1.67; 95% CI, 1.31–2.15) was associated with increased odds of developing severe PGD ( p < 0.001 for both). Conclusions Amiodarone use pre-OHT is independently associated with increased incidence of severe PGD and in-hospital mortality and linearly associated with increased incidence of severe PGD in a dose-dependent manner. [ABSTRACT FROM AUTHOR]

Experience with bariatric surgery in patients after orthotopic heart transplantation (OHT) is still limited. We performed a retrospective review of patients who underwent bariatric surgery after OHT from January 1, 2010 to December 31, 2016. Two post-OHT patients with BMI of 37.5 and 36.2 kg/m² underwent laparoscopic robotic-assisted Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy, respectively. Quality of life substantially improved for both patients. Bariatric surgery is safe and feasible in OHT patients, despite numerous risk factors. Careful selection of patients is required with proper preoperative management and overall care. Due to the complexity of treatment and perioperative care in this specific population, these operations should be done in high-volume centers with multidisciplinary teams composed of bariatric, cardiac transplant surgeons and critical care physicians. Bariatric surgery can be highly effective for treatment of obesity after OHT. [ABSTRACT FROM AUTHOR]

Cardiac allograft vasculopathy is a major cause of morbidity and mortality in orthotopic heart transplantation. The optimal management remains uncertain, especially in left main coronary artery lesions. With the limited data available in the literature, we present a review of three pediatric cases of cardiac allograft vasculopathy, involving the left main coronary artery, treated with percutaneous coronary intervention.

Heart failure, whether acute or chronic, remains a major health care crisis affecting almost 6 million Americans and over 23 million people worldwide. Roughly half of those affected will die within 5 years, and the annual cost exceeds $30 billion in the US alone. Although medical therapy has made some modest inroads in partially stemming the heart failure tsunami, there remains a significant population for whom medication is unsuccessful or has ceased being effective; such patients can benefit from heart transplantation or mechanical circulatory support. Indeed, in the past quarter century (and as covered in Cardiovascular Pathology over those years), significant improvements in pathologic understanding and in engineering design have materially enhanced the toolkit of options for such refractory patients. Mechanical devices, whether total artificial hearts or ventricular assist devices, have been reengineered to reduce complications and basic wear and tear. Transplant survival has also been extended through a better comprehension of and improved therapies for transplant vasculopathy and antibody-mediated rejection. Here we review the ideas and treatments from the last 25 years and highlight some of the new directions in nonpharmacologic heart failure therapy. [ABSTRACT FROM AUTHOR]

Aim. To evaluate dynamic of physical capability (PC) based on bicycle ergometry test data in different post- operation terms after orthotopic heart transplantation (OHT). Methods and results. In 28 patients aged from 19 to 59 (mean 45,9 ± 2,2) years the dynamics of PC values was assessed at 14–36 (mean 20,8 ± 1,6) months after OHT. Prior to surgery, all 28 patients had low exercise tolerance (ET) as well as low maximal oxygen consump- tion (VO2max). A significant increase in ET and VO2max was registered in 6 and 12 months after OHT compared to baseline (р < 0,05), a trend to increasing PC values was noted in 6 to 12 months after OHT compared to baseline, 3 (20%) of 15 patients examined showed myocardial ischemia. Conclusion. The PC decrease revealed in 14–36 months after OHT may be indicative of vasculopathy development or progressive underlying athero- sclerotic process.

Objective: Although several studies have described the effects of adriamycin on the heart, electrocardiographic total 12-lead QRS voltage (distance in millimeters from the peak of the R wave to the nadir of either the Q or S wave, whichever was deeper, with 10 mm [1 mV] being standard) both before and after orthotopic heart transplantation (OHT) has not been reported. This study describes the total 12-lead QRS voltage in 8 patients studied at Baylor University Medical Center at Dallas, from 1994 to June 2018, who underwent OHT for severe heart failure caused by anthracycline-induced cardiomyopathy. Method: Prior to OHT, the total 12-lead non-paced QRS voltages ranged from 86 to 189 mm (mean 125 ± 56) and for paced QRS voltages from 82 to 113 mm (mean 97 ± 15). The total 12-lead QRS voltages post-OHT ranged from 100 to 190 mm (mean 130 ± 30). Total 12-lead QRS voltages were lower in patients with a pacemaker than without. Results/Conclusion: These low voltages are like those found in patients with carcinoid syndrome, severe cardiac adiposity, cardiac amyloidosis, and cardiac sarcoidosis. [ABSTRACT FROM AUTHOR]

Key Clinical Message: We report a first case of a highly complicated lead extraction in a young man who previously underwent orthotopic heart transplantation (OHT).Lead extraction in transplanted patients may be a feasible and safe procedure in order to maintain a low infective risk and to preserve alternative vascular access sites. We report a first case of a highly complicated lead extraction in a young man who previously underwent orthotopic heart transplantation (OHT).Lead extraction in transplanted patients may be a feasible and safe procedure in order to maintain a low infective risk and to preserve alternative vascular access sites. [ABSTRACT FROM AUTHOR]

This article presents a retrospective analysis of infectious complications in the structure of morbidity and mortality of the patients underwent orthotopic heart transplantation. A significant role was assigned to the predisposing to in- fection factors. This study was based on the two years heart transplantation experience in the Republic of Belarus.

The selection of recipients for the orthotopic heart transplantation is of great importance. In 2006–2009 we examined 25 tests on reversibility of pulmonary hypertension, i.e. in 14 patients with dilated cardiomyopathy (DCM) (11 males and 3 females aged 41,1 ± 9,3) and in 11 patients with coronary artery disease (CAD) (all males aged 50 ± 4.9). Initial pulmonary vascular resistance (PVR) was 3,61 ± 1,02 and 3,59 ± 0,98 respectively. Alprostadil was infused to all the patients. Pulmonary hypertension was irreversible in 4 (28,5%) DCM patients and in 2 (18%) CAD patients. Initial PVR in those patients was 6,27 ± 3,2 and 5,7 ± 2,4 respectively. The average alprostadil dose necessary for the reverse of pulmonary hypertension was 0,054 ± 0,027 μg/kg/min in DCM patients, and 0,047 ± 0,022 μg/kg/min in CAD patients. Thus, the application of alprostadil for the pharmacological correction of pulmonary vascular resistance is most effective in patients with moderate pulmonary hypertension according to Rich classification.

Objective To investigate the early application value of echocardiography(UCG) after orthotopic heart transplantation(OHT). Methods A total of 29 patients were monitored by UCG early after OHT. On the 1st, 7th, 14th, 30th day after operation, the left ventricular end-diastolic diameter (LVDd) and right ventricular end-diastolic diameter (RVDd), interventricular septal thickness (IVST), left ventricular posterior wall thickness (LVPWT) and the tricuspid regurgitation area (TRA) were measured, and the left ventricular ejection fraction (LVEF) and left ventricle Tei index(LV-Tei) were calculated. The blood pressures (BP), central venous pressure (CVP) of the patients were recorded simultaneously. Results The LVDd were larger on the 7th, 14th and 30th day after operation, while the RVDd were smaller, compared with those on the 1st day after operation (all in P < 0.05). The IVST, LVPWT were lower on the 1th, 14th and 30th day after operation, compared with those on the 7th day after operation (all in P < 0.05). The BP, CVP, LV-Tei were all significantly lower on the 1st, 14th and 30th day after operation, compared with those on the 7th day after operation (P < 0.05). There was no significant difference in LVEF between each time points(P>0.05). The tricuspid regurgitation was detected in 3-4 d after operation by UCG, and the TRA reached the peak value[(9.2±2.5)cm2] in 5-8 d after operation, then gradually decreased to (4.7±2.4)cm2 at 1 month after operation. Conclusions Early phase after OHT, the structure and function of transplanted heart can be monitored effectively by echocardiography, and it can timely provide multiple parameters as the basis of diagnosis and treatment for clinical doctors. [ABSTRACT FROM AUTHOR]

Background Previous studies reported that left ventricular noncompaction (LVNC) is a cardiomyopathy, familial or sporadic, arising from arrest of the normal process of trabecular remodeling during embryonic development. The diagnosis is usually made by echocardiography, but to date, there has been little research on the occurrence and clinicopathological features of LVNC in the explanted hearts of orthotopic heart transplant (OHT) recipients. Design The clinical, echocardiographic, and pathologic findings were reviewed for evidence of LVNC, diagnosed by echocardiographic criteria, in 105 patients with end-stage heart failure (HF) undergoing OHT. Analyses of multiple sections of the explanted hearts were carried out. The hearts were evaluated for grades (0, negative; 1, mild/occasional foci; 2, moderate/multiple foci; 3, severe/extensive, diffuse) of fibrosis, reactive and replacement, hypertrophy, myocytolysis in left ventricle, right ventricle, interventricular septum, and atria. Absolute measurements of noncompacted and compacted portions of the left ventricle wall and noncompacted/compacted ratios were calculated. Results Isolated LVNC was observed in 0 of 54 ischemic cardiomyopathy and in 4 of 51 (7.8%) nonischemic cardiomyopathy patients — 2 men and 2 women, with a mean age ± SEM of 34.2 ± 6.9 years. The echocardiogram disclosed marked left ventricular dilatation, prominent trabeculations, and left ventricle ejection fraction < 20%. Mural thrombi were seen in 3 of 4 (75%) patients. The heart weight mean ± SEM was 468 ± 55.3 g (range, 340–600 g); noncompacted myocardium was 22 ± 5.8 mm, compacted myocardium was 13.2 ± 3.5 mm, and noncompacted/compacted ratio was 1.7/1 ± 0.2. The total scores of hypetrophy, myocytolysis, and fibrosis were as follows: left ventricle, 7.7 ± 0.2; right ventricle, 6.2 ± 0.5; interventricular septum, 6.7 ± 0.2; and atria, 7.5 ± 0.3. Conclusions LVNC is an unusual form of nonischemic cardiomyopathy in patients suffering from end-stage HF undergoing OHT. The variability in the noncompacted/compacted ratio and discordance between the echocardiographic and pathological findings points to the need for further clarification of diagnostic imaging and diagnostic criteria for LVNC. Further studies in larger series, correlating the anatomoclinical and genetic variables, also would improve our understanding of LVNC as a cause of advanced HF leading to OHT. [ABSTRACT FROM AUTHOR]

Background Heart transplantation is increasing in patients with adult congenital heart disease (ACHD). In this population, the association of pulmonary hypertension (PH) with post-transplant outcomes is not well-defined. Methods Using data from the United Network for Organ Sharing database (1987 to 2014), we identified ACHD patients listed for heart transplantation, and examined survival between those with and without PH (pre-transplant PH defined as transpulmonary pressure gradient >12 mm Hg). Results Among 983 ACHD patients, 216 (22%) had PH. At time of listing, PH patients had a transpulmonary pressure gradient of 17.0 mm Hg vs 6.0 mm Hg ( p < 0.01) in the no-PH group. Although left ventricular assist device (LVAD) use was infrequent, 3.1% of PH patients were treated with an LVAD versus 6.8% of the no-PH patients. Days from listing to transplant, days from listing to death on the waitlist and length of post-transplant hospitalization were not significantly different between the PH and no-PH groups. However, PH was associated with higher waitlist mortality (HR 1.73, CI 1.25 to 2.41). Pre-transplant PH was not associated with post-transplant mortality at 30 days (HR 0.51, CI 0.23 to 1.13), 1 year (HR 0.68, 95% CI 0.40 to 1.18) or 5 years (HR 0.84, 95% CI 0.55 to 1.29). Conclusions PH is common among ACHD patients listed for transplant and is associated with increased waitlist mortality. Conversely, PH was not associated with worse survival after transplant. Bridge-to-transplant LVAD therapy was uncommon in this ACHD population. [ABSTRACT FROM AUTHOR]

Background To date, there has been little research, if any, on the pathological correlates of end-stage heart failure in the explanted hearts of orthotopic heart transplant (OHT) recipients in correlation with the patients’ hemodynamics. We sought to compare the gross and histopathological parameters in hearts explanted—native or previously transplanted—from patients with end-stage heart failure with the clinical hemodynamics parameters at the time of OHT. Methods Forty patients undergoing OHT were enrolled in this study and divided into two groups according to whether they suffered from ischemic (ICMP) or nonischemic cardiomyopathy (NICMP). All study patients were treated with OHT for end-stage heart failure at The University of Texas Health Science Center at Houston. The pathological investigations of the hearts were focused on the study of the underlying cause of heart failure leading the patient to OHT; on the quantification of the extent and severity of fibrosis, hypertrophy, and myocytolysis; and on validating a semiquantitative grading scale. Analyses of multiple sections of the explanted hearts were carried out. The heart weights were recorded and compared with the grades of fibrosis, hypertrophy of cardiomyocytes, and myocytolysis. The grades of fibrosis, hypertrophy, and myocytolysis were evaluated in right and left ventricles and atria (with areas of confluent infarction excluded). The pathological parameters were correlated with the patients’ clinical parameters. Results Twenty-two patients (20 men, 2 women, mean age±S.E.M., 62.3±2.2 years) suffered from ICMP and 18 patients (9 men, 9 women, mean age±S.E.M., 56.3±2.8 years) from NICMP. All the clinical and pathological measured variables were comparable between the two groups, except for pulmonary vascular resistance, which was higher in the NICMP group of patients, and the grade of myocytolysis, which was significantly higher in the ICMP vs. NICMP group. Most of the clinical and pathological variables were overall linearly correlated. Conclusions Both ICMP and NICMP groups of end-stage heart failure requiring OHT presented high grades of fibrosis, hypertrophy, and myocytolysis. Heart failure is the final common pathway of a variety of primary cardiovascular diseases regardless of the ischemic or nonischemic nature of the cardiomyopathy. [ABSTRACT FROM AUTHOR]

Infections produced by Mycobacterium abscessus are emerging in immunosuppressed patients, such as solid organ transplant recipients. We report the first case, to our knowledge, of a vertebral osteomyelitis caused by M. abscessus in a heart transplant recipient, and review the risk factors, manifestations, and therapeutic approaches to this uncommon disease. [ABSTRACT FROM AUTHOR]

Clinical echocardiographic assessment of left ventricular (LV) systolic and diastolic function is routinely performed following orthotopic heart transplantation (OHT). The purpose of this study was to determine whether echocardiographic indices of LV diastolic function correlate with pulmonary capillary wedge pressure (PCWP) in the transplanted heart. Patients who had OHT between June 2009 and November 2011 underwent transthoracic echocardiography and right heart catheterization (RHC) at approximately 1 year post transplantation. We retrospectively assessed 33 potential parameters of LV diastolic function using 2-dimensional, spectral Doppler and tissue Doppler echocardiography. We measured PCWP by RHC. We compared echocardiographic measures with PCWP using linear regression analysis. Ninety-five patients (mean age 49 ± 13 years, 73 males, mean LV ejection fraction 62 ± 10 %) were included in the study. Overall, echocardiographic parameters of LV diastolic function demonstrated poor correlation with PCWP. By linear regression, the parameter that most strongly correlated with PCWP was left atrial (LA) minimum area in the apical 4-chamber view ( p = 0.002, r = 0.1). Comparing patients with PCWP ≤ 12 mmHg and those with PCWP > 12 mmHg, the parameter that demonstrated the most significant difference was LA minimum area in the apical 2-chamber view ( p = 0.002), and comparing patients with PCWP ≤ 15 mmHg and those with PCWP > 15 mmHg, the most significant difference was peak early diastolic velocity of the mitral annulus ( p = 0.02). In patients with cardiac allografts, clinical echocardiographic measures of LV diastolic function correlate poorly with PCWP. [ABSTRACT FROM AUTHOR]

This study was initiated to assess the temporal trends of renal function, and define risk factors associated with worsening renal function in pediatric heart transplant recipients in the immediate post-operative period. We performed a single-center retrospective study in children ≤18 yr receiving OHT (1993-2012). The AKIN's validated, three-tiered AKI staging system was used to categorize the degree of WRF. One hundred sixty-four patients qualified for inclusion. Forty-seven patients (28%) were classified as having WRF after OHT. Nineteen patients (11%) required dialysis after heart transplantation. There was a sustained and steady improvement in renal function in children following heart transplantation in all age groups, irrespective of underlying disease process. The significant factors associated with risk of WRF included body surface area ( OR: 1.89 for 0.5 unit increase, 95% CI: 1.29-2.76, p = 0.001) and use of ECMO prior to and/or after heart transplantation ( OR: 3.50, 95% CI: 1.51-8.13, p = 0.004). Use of VAD prior to heart transplantation was not associated with WRF ( OR: 0.50, 95% CI: 0.17-1.51, p = 0.22). On the basis of these data, we demonstrate that worsening renal function improves early after orthotopic heart transplantation. [ABSTRACT FROM AUTHOR]

Objective To investigate the early application value of echocardiography (UCG) alter orthotopic heart transplantation (OHT). Methods A total of 29 patients were monitored by UCG early alter OHT. On the 1st, 7th, 14th, 30th day after operation, the left ventricular end-diastolic diameter (LVDd) and right ventricular end-diastolic diameter (RVDd), interventricular septal thickness (IVST), left ventricular posterior wall thickness (LVPWT) and the tricuspid regurgitation area (TRA) were measured, and the left ventricular ejection fraction (LVEF) and left ventricle Tei index (LV-Tei) were calculated. The blood pressures (BP). central venous pressure (CVP) of the patients were recorded simultaneously. Results The LVDd wen-larger on the 7th. 14th and 30th day after operation, while the RVDd wenth smaller, compared with those on the 1st day after operation (all in P < 0.05). The IVST, LVPWT were lower on the 1st. 14th and 30th day after operation, compared with those on the 7th day alter operation (all in P <0.05). The BP, CVP, LV-Tei were all significantly lower on the 1st, 14th and 30th day alter operation, compared with those on the 7th day after operation (P <0.05). There was no significant difference in LVEF between each time points (P > 0.05). The tricuspid regurgitation was detected in 3-4 d alter operation by UCG, and the TRA reached the peak value (9.2 ±2.5) cm2 in 5-8 d alter operation, then gradually decreased to (4.7 ±2.4) cm2 at 1 month after operation. Conclusions Early phase alter OHT. the structure and function of transplanted heart can be monitored effectively by echocardiography, and it can timely provide multiple parameters as the basis of diagnosis and treatment for clinical doctors. [ABSTRACT FROM AUTHOR]

Cardiac allograft vasculopathy (CAV) remains one of the leading causes of death and graft failure after heart transplantation. A variety of causes, including donor heart characteristics, recipient risk factors, and immune-mediated influences, are associated with developing CAV. In this review, we will focus on the pathophysiology of developing CAV and various methods to screen for this condition. The pathogenesis of CAV likely involves repeated injuries to the endothelium from a variety of factors such as cellular-mediated rejection, and alloimmune factors, including antibody-mediated injury, ischemia-reperfusion injury at time of transplant, cytomegalovirus infections, immunosuppression medications, systemic inflammation, and traditional atherosclerosis risk factors. Patients with significant CAV are often asymptomatic, and therefore early detection by routine screening prior to graft dysfunction is crucial. There are a variety of invasive, noninvasive, and blood tests that have been studied as screening methods, and we will discuss the role of each of these in this review article. Although some treatment regimens have been established for CAV, this is an area where further studies and research are necessary. [ABSTRACT FROM AUTHOR]

Background: Predicting complications associated with pulmonary hypertension (PH) after cardiac transplantation is an important factor when considering cardiac transplantation. The transpulmonary gradient (TPG) is recommended to quantify PH in transplant candidates. Nonetheless, PH remains a common driver of mortality. The diastolic pressure gradient (DPG) and pulmonary vascular resistance (PVR) can differentiate post- from combined pre- and post-capillary PH and may improve estimation of PH-associated risks. We used a large European cohort of transplant candidates to assess whether the pulmonary pulsatility index (PAPi), improves prediction of graft failure and mortality compared to DPG and PVR., Methods: Out of all patients undergoing heart transplantation between 2009 and 2019 in Eurotransplant member states ( n = 10,465), we analyzed the impact of PH (mPAP > 25 mmHg) and right heart catheter hemodynamic data on graft failure and mortality within 1-5 years., Results: In 1,407 heart transplant patients with PH (79% male, median age 54 years, IQR 39-69 years), the median PVR was 2.5 WU (IQR 1.6 WU) with a median mPAP (pulmonary arterial pressure) of 32 mmHg (IQR 9 mmHg). Patients with low (< 3 mmHg) DPG had a better 5 year survival than those with higher DPG (log rank p = 0.023). TPG, mPAP, PAPi, and PVR did not improve prediction of survival. Low PAPi ( OR = 2.24, p < 0.001) and high PVR ( OR = 2.12, p = 0.005) were associated with graft failure., Conclusion: PAPI and PVR are associated with graft failure in patients with PH undergoing cardiac transplantation. DPG is associated with survival in this cohort., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Wagner, Magnussen, Bernhardt, Smits, Steinbach, Reichenspurner, Kirchhof and Grahn.)

Data are limited on the efficacy and safety of bortezomib for the treatment of AMR following OHT for pediatric acquired or CHD. Retrospective chart review identified patients who received bortezomib for acute (n = 3, within two wk of diagnosis) and chronic (n = 1, three months after diagnosis) AMR or as part of a desensitization regimen (n = 1). Bortezomib was associated with a 3-66% reduction in class I DSA and a 7-82% reduction in class II DSA. Two of the three acute AMR cases resolved by the first follow-up biopsy. Two patients with AMR resolution are currently well. One patient developed a second episode of AMR, which was unresponsive to bortezomib therapy and required retransplantation for progressive coronary allograft vasculopathy. One patient died shortly after the third cycle from multi-organ failure. The desensitization patient showed transient HLA reduction with two cycles, but died five months after transplant from sepsis. Complications included infection (3/5), peripheral neuropathy (2/5), AKI (2/5), and thrombocytopenia (3/5). Adverse events appear more common in critically ill patients. Bortezomib therapy resulted in variable DSA reduction and AMR resolution in AMR in OHT secondary to pediatric acquired or CHD. [ABSTRACT FROM AUTHOR]

Background: Although the transpulmonary gradient (TPG) and pulmonary vascular resistance (PVR) are commonly used to differentiate heart failure patients with pulmonary vascular disease from those with passive pulmonary hypertension (PH), elevations in TPG and PVR may not always reflect pre-capillary PH. Recently, it has been suggested an elevated diastolic pulmonary artery pressure–to–pulmonary capillary wedge pressure gradient (DPG) may be a better indicator of pulmonary vascular remodeling, and therefore, may be of added prognostic value in patients with PH being considered for cardiac transplantation. Methods: Using the United Network for Organ Sharing (UNOS) database, we retrospectively reviewed all primary adult (age > 17 years) orthotropic heart transplant recipients between 1998 and 2011. All patients with available pre-transplant hemodynamic data and PH (mean pulmonary artery pressure ≥ 25 mm Hg) were included (n = 16,811). We assessed the prognostic value of DPG on post-transplant survival in patients with PH and an elevated TPG and PVR. Results: In patients with PH and a TPG > 12 mm Hg (n = 5,827), there was no difference in survival at up to 5 years post-transplant between high DPG (defined as ≥3, ≥5, ≥7, or ≥10 mm Hg) and low DPG (<3, <5, <7, or <10 mm Hg) groups. Similarly, there was no difference in survival between high and low DPG groups in those with a PVR > 3 Wood units (n = 6,270). Defining an elevated TPG as > 15 mm Hg (n = 3,065) or an elevated PVR > 5 (n = 1,783) yielded similar results. Conclusions: This large analysis investigating the prognostic value of DPG found an elevated DPG had no effect on post-transplant survival in patients with PH and an elevated TPG and PVR. [Copyright &y& Elsevier]

Background: Orthotopic heart transplant (OHT), followed by myeloablative chemotherapy and autologous stem cell transplant (ASCT), has been successful in the treatment of amyloid light-chain (AL) cardiac amyloidosis. The purpose of this study was to identify predictors of survival to OHT in patients with end-stage heart failure due to AL amyloidosis and compare post-OHT survival of cardiac amyloid patients with survival of other cardiomyopathy patients undergoing OHT. Methods: From January 2000 to June 2011, 31 patients with end-stage heart failure secondary to AL amyloidosis were listed for OHT at Massachusetts General Hospital. Univariate and multivariate regression analyses identified predictors of survival to OHT. Kaplan-Meier analysis compared survival between the Massachusetts General Hospital amyloidosis patients and non-amyloid cardiomyopathy patients from the Scientific Registry of Transplant Recipients (SRTR). Results: Low body mass index was the only predictor of survival to OHT in patients with end-stage heart failure caused by cardiac amyloidosis. Survival of cardiac amyloid patients who died before receiving a donor heart was only 63 ± 45 days after listing. Patients who survived to OHT received a donor organ at 53 ± 48 days after listing. Survival of AL amyloidosis patients on the waiting list was less than patients on the waiting list for all other non-amyloid diagnoses. The long-term survival of amyloid patients who underwent OHT was no different than the survival of non-amyloid, restrictive (p = 0.34), non-amyloid dilated (p = 0.34), or all non-amyloid cardiomyopathy patients (p = 0.22) in the SRTR database. Conclusions: Amyloid patients who survive to OHT, followed by ASCT, have a survival rate similar to other cardiomyopathy patients undergoing OHT; however, 35% of the patients died awaiting OHT. The only predictor of survival to OHT in AL amyloidosis patients was a low body mass index, which correlated with a shorter time on the waiting list. To optimize the survival of these patients, access to donor organs must be improved. [ABSTRACT FROM AUTHOR]