Prediction of long-term (> 10 year) cardiovascular outcomes in heart transplant recipients: Value of stress technetium-99m tetrofosmin myocardial perfusion imaging.

BACKGROUND: Myocardial perfusion imaging (MPI) using single-photon emission computed tomography (SPECT) is useful in the evaluation of cardiac allograft vasculopathy (CAV) in heart transplant (HTx) recipients. The current study evaluated the long-term prognostic value of stress SPECT MPI for predicting all-cause mortality and cardiac events in HTx recipients. METHODS: The study population consisted of 166 HTx recipients (mean age 54 ± 10 years, 84% male) who underwent exercise or dobutamine stress 99mTc-tetrofosmin SPECT MPI for the assessment of CAV. An abnormal SPECT MPI was defined as the presence of a fixed or a reversible perfusion defect. Endpoints were all-cause mortality, cardiac mortality, and non-fatal myocardial infarction (MI). RESULTS: MPI abnormalities were detected in 55 patients (33%), including fixed defects in 28 patients (17%), partially reversible in 17 patients (10%), and completely reversible defects in 10 patients (6%). During a median follow-up of 12.8 years (range 0-15, mean follow-up 9.5 years), 109 (66%) patients died (all-cause mortality), of which 67 (40%) were due to cardiac causes. A total of 5 (3%) patients experienced a non-fatal MI. HTx recipients with a normal stress 99mTc-tetrofosmin SPECT MPI had a significantly better prognosis as compared with those with an abnormal study, up to 5 years after the initial test. The presence of a reversible perfusion defect was a significant predictor of all-cause mortality, cardiac mortality, and major cardiac events, during the entire follow-up period. CONCLUSIONS: Stress 99mTc-tetrofosmin SPECT MPI provides valuable prognostic information for the prediction of long-term outcome in HTx recipients. Patients with a normal stress 99mTc-tetrofosmin SPECT MPI have a significantly better prognosis as compared with those with an abnormal study, up to 5 years after initial testing.

Opinions of lung cancer clinicians on shared decision making in early-stage non-small-cell lung cancer.

OBJECTIVES: To investigate the opinions of lung cancer clinicians concerning shared decision making (SDM) in early-stage non-small-cell lung cancer patients. METHODS: A survey was conducted among Dutch cardiothoracic surgeons and lung surgeons, pulmonologists and radiation oncologists. The opinions of clinicians on the involvement of patients in treatment decision making was assessed using a 1-5 Likert-type scale. Through open questions, we queried barriers to and drivers of SDM in clinical practice. Clinicians were asked to review 7 hypothetical cases and indicate which treatment strategy they would choose using a 1-7 Likert-type scale. RESULTS: Twenty-six percent of surgeons, 20% of pulmonologists and 12% of radiation oncologists indicated that they always engage in SDM (16% missing; P-value = 0.10). Most respondents stated that, ideally, doctors and patients should decide together (surgeons 52%, pulmonologists 67% and radiation oncologists 35%; P-value = 0.005). Thirty percent of surgeons, 27% of pulmonologists and 44% of radiation oncologists indicated that doctors are not properly trained to implement SDM in clinical practice (P-value = 0.37). SDM may not always be feasible due to low patient education level and minimal knowledge about lung cancer. Wide variations in the clinicians' lung cancer treatment preferences were observed in the responses to the hypothetical cases. CONCLUSIONS: In current clinical decision making in lung cancer treatment, a majority of clinicians agree that it is important to involve lung cancer patients in treatment decision making but that time constraints and the inability of some patients to make a weighted decision are important barriers. The observed variation in lung cancer treatment preferences among clinicians suggests that for most patients both surgery and radiotherapy are suitable options, and it underlines the sensitive nature of treatment choices in early-stage non-small-cell lung cancer.

Predicting Overall Survival After Stereotactic Ablative Radiation Therapy in Early-Stage Lung Cancer: Development and External Validation of the Amsterdam Prognostic Model.

PURPOSE: A prognostic model for 5-year overall survival (OS), consisting of recursive partitioning analysis (RPA) and a nomogram, was developed for patients with early-stage non-small cell lung cancer (ES-NSCLC) treated with stereotactic ablative radiation therapy (SABR). METHODS AND MATERIALS: A primary dataset of 703 ES-NSCLC SABR patients was randomly divided into a training (67%) and an internal validation (33%) dataset. In the former group, 21 unique parameters consisting of patient, treatment, and tumor factors were entered into an RPA model to predict OS. Univariate and multivariate models were constructed for RPA-selected factors to evaluate their relationship with OS. A nomogram for OS was constructed based on factors significant in multivariate modeling and validated with calibration plots. Both the RPA and the nomogram were externally validated in independent surgical (n = 193) and SABR (n = 543) datasets. RESULTS: RPA identified 2 distinct risk classes based on tumor diameter, age, World Health Organization performance status (PS) and Charlson comorbidity index. This RPA had moderate discrimination in SABR datasets (c-index range: 0.52-0.60) but was of limited value in the surgical validation cohort. The nomogram predicting OS included smoking history in addition to RPA-identified factors. In contrast to RPA, validation of the nomogram performed well in internal validation (r(2) = 0.97) and external SABR (r(2) = 0.79) and surgical cohorts (r(2) = 0.91). CONCLUSIONS: The Amsterdam prognostic model is the first externally validated prognostication tool for OS in ES-NSCLC treated with SABR available to individualize patient decision making. The nomogram retained strong performance across surgical and SABR external validation datasets. RPA performance was poor in surgical patients, suggesting that 2 different distinct patient populations are being treated with these 2 effective modalities.

Comparison of clinical outcome of stage I non-small cell lung cancer treated surgically or with stereotactic radiotherapy: results from propensity score analysis.

OBJECTIVES: Guideline-specified curative therapies for a clinical stage I non-small cell lung cancer (NSCLC) are either lobectomy or Stereotactic Ablative Radiotherapy (SABR). As outcomes of prospective randomized clinical trials comparing these modalities are unavailable, we performed a propensity-score matched analysis to create two similar groups in order to compare clinical outcomes. METHODS: We selected 577 patients, 96 VATS or open lobectomy were treated at Erasmus University Medical Center Rotterdam and 481 SABR patients were treated at VU University Medical Center Amsterdam with clinical stage I NSCLC. RESULTS: Matching of patients according to propensity score resulted in a cohort that consisted of 73 patients in the surgery group and of 73 patients in the SABR group. Median follow-up in the surgery and SABR group was 49 months and 28 months, respectively. Overall survival of patients who underwent surgery was 95% and 80% at 12 and 60 months, respectively. For the SABR group this was 94% at 12 months and 53% at 60 months. No statistical significant difference (p=0.089) in survival was found between these groups. CONCLUSIONS: In this study we found no significant differences in overall survival in propensity matched patients diagnosed with stage I NSCLC treated either surgically or with SABR. After 3 years there seems to be a trend toward improved survival in patients who were treated surgically.

Survival and treatment of non-small cell lung cancer stage I-II treated surgically or with stereotactic body radiotherapy: patient and tumor-specific factors affect the prognosis.

BACKGROUND: This study was designed to define clinical baseline parameters associated with impaired survival of patients with stage I or II non-small cell lung cancer (NSCLC) who underwent surgery or stereotactic body radiotherapy (SBRT). METHODS: From January 2001 to January 2011, 425 patients (216 surgery, 209 SBRT) were identified with clinical stage I or II NSCLC. Cox proportional-hazards regression analyses were used to investigate risk factors for mortality. RESULTS: Median age of patients in the surgery and SBRT groups was 65 and 74 years, respectively. A smaller proportion of the surgical group had Charlson Comorbidity Index (CCI) score ≥1 compared with the SBRT group: 52 and 72 % (p < 0.001), respectively. Overall survival in the surgical group at 2 and 4 years was 79 and 65 %, respectively. In the SBRT group, this was 65 % at 2 years and 44 % at 4 years. In the surgical group older age, CCI score = 4 and clinical stage = IIB were associated with long-term mortality. In the SBRT group, this was CCI score ≥5 and clinical stage >IA. The area under the curve was calculated for the model with clinical and tumor factors: 0.77 for the surgery and 0.85 for the SBRT group. CONCLUSIONS: Both patient characteristics and survival of NSCLC I-II patients undergoing surgical treatment or SBRT differ considerably. Long-term survival as a result of treatment strategy of NSCLC patients might be optimized by focusing on patient and tumor specific factors. In addition to TNM staging, the consideration of patient age and CCI can be useful for prognostication of NSCLC patients.

Performance indicators for lung cancer surgery in the Netherlands.

OBJECTIVES: In the Netherlands, surgery for lung cancer is traditionally performed in low-volume hospitals. To assess the need for centralization, we examined early outcome measures and compared results between hospitals and with other European countries. METHODS: Data on patient, tumour and treatment characteristics were retrieved from the Netherlands Cancer Registry. Results were tabulated for 30-day postoperative mortality (POM), major morbidity rate (intrathoracic empyema, bronchopleural fistula or rethoracotomy) and pneumonectomy proportion. Hospital variation was projected using funnel graphs in which the results for individual hospitals are plotted against volume. RESULTS: The study comprised a series of 9579 patients with primary non-small cell lung cancer, diagnosed from 2005 through 2010 and operated in 79 different hospitals. The POM was 2.7% on average and age, gender, period and type of surgery were determined as prognostic factors. Multivariable analysis did not reveal an association with hospital volume (P = 0.34). The POM was higher for operations on Fridays (4.0%) or during weekends (6.8%). Major morbidity was observed after 8.3% of operations and was more frequent after bilobectomy (11.6%) or right pneumonectomy (22%). The pneumonectomy proportion decreased from 18% in 2005 to 11% in 2010. Funnel plots revealed a limited number of significant outliers, despite combining data over a 6-year period. CONCLUSIONS: Results for the Netherlands were similar to those from other European countries. Hospital volume was not associated with early outcome indicators. Quality assessment at the hospital level remains a major challenge given the low frequency of adverse events and the impediments of chance variation.

Validation of a prognostic model to predict survival after non-small-cell lung cancer surgery.

OBJECTIVE: Surgery is the first choice of treatment for localised non-small-cell lung cancer (NSCLC). When making decisions regarding resection, physicians must balance the potential long-term benefits of surgery with the risk of surgery-related death, particularly among elderly patients with multiple co-morbid conditions. In 2005, a predictive model with a preoperative and a postoperative mode to predict survival of an individual patient after NSCLC surgery was created. This model combines the patient-, tumour- and treatment characteristics and can be used to assist in clinical decision making. Till present, this model has not been validated. The purpose of this study was to validate this model in patients operated on for primary NSCLC. METHODS: A total of 126 patients underwent surgery for primary NSCLC between January 2002 and December 2006. Required model variables were collected for all patients and inserted into the model. To evaluate the performance of the two models, we assessed these models in terms of both discrimination (resolution) and calibration (reliability). The discriminative ability was measured using the c-index and calibration was evaluated by the Hosmer-Lemeshow goodness-of-fit test. RESULTS: The median follow-up time was 3.4 years. Hospital mortality was 2.4%. One-, 2- and 3-year survival was 86%, 75% and 72%, respectively. The discriminative ability of the preoperative mode showed a c-statistic for 1-year survival of 0.68, for 2-year of 0.68 and for 3-year of 0.66. The postoperative model showed a discriminative ability for 1-year survival of 0.72, for 2-year of 0.76 and for 3-year of 0.77. Calibration was adequate for the first 2 years. The preoperative mode showed a p-value of 0.62 for 1-year survival and 0.14 for 2-year survival. Calibration was poor for 3-year survival (p=0.0027). For the postoperative mode, calibration was quite similar with p-values of 0.4 for 1-year survival, 0.14 for 2-year survival and 0.003 for 3-year survival. CONCLUSIONS: The model adequately estimates the 1- and 2-year survival. Discrimination was good for 3-year survival. Inclusion of more factors with additional prognostic value could potentially further improve the accuracy of the model.

Inadequate immune regulatory function of CD4+CD25bright+FoxP3+ T cells in heart transplant patients who experience acute cellular rejection.

BACKGROUND: CD4CD25FoxP3 regulatory T cells are suppressors of antigen-activated immune reactivity. Here, we assessed the clinically relevant role of these cells in the control of immune responses directed to a transplanted heart. METHODS: We investigated the phenotype and function of peripheral CD4CD25FoxP3 T cells in heart transplant patients free from acute rejections (n=9) and in rejectors (n=12) before and during acute cellular rejection. RESULTS: Between rejectors and nonrejectors, the proportion of CD4CD25 T cells and of FoxP3 cells within this population was comparable. Yet, CD4CD25FoxP3 T cells of rejectors had a higher CD127 expression than those of nonrejectors (P<0.0001). Depletion of CD4CD25 T cells from peripheral blood mononuclear cells increased the antidonor proliferative response of both nonrejectors (P=0.0005) and rejectors (P=0.03). In rejectors, however, only a 2-fold increase was measured, whereas the nonrejectors' response became 14 times higher (P=0.002). Reconstitution of CD4CD25 T cells only suppressed the overall antidonor proliferative response of CD25 responder cells of nonrejectors significantly (P=0.001). Moreover, the percentage inhibition of the response was higher in nonrejectors than in rejectors (P=0.02). Analyses of pretransplant samples revealed that CD4CD25 T cells of rejectors already had a lower suppressive capacity than those of nonrejectors before transplantation (P=0.04). CONCLUSION: CD4CD25FoxP3 T cells of heart transplant patients who experience acute rejection had an up-regulated CD127 expression and an inadequate regulatory function compared with those of nonrejecting patients. Our observations suggest that the function of circulating CD4CD25FoxP3 regulatory T cells may be pivotal for the prevention of acute cellular rejection after clinical heart transplantation.

FOXP3 mRNA expression analysis in the peripheral blood and allograft of heart transplant patients.

Previously, we demonstrated in heart transplant patients that FOXP3, a gene required for the development and function of regulatory T cells, was highly expressed in the graft during an acute cellular rejection. In this study, we analyzed whether the FOXP3 gene expression in the peripheral blood also reflects anti-donor immune responses, and therefore may provide clues for non-invasive detection of non-responsiveness or acute rejection. We examined the FOXP3 expression patterns of peripheral blood mononuclear cells (PBMC; n=69) of 19 heart transplant patients during quiescence and rejection in comparison with those of endomyocardial biopsies (EMB; n=75) of 24 heart transplant patients. While the FOXP3 mRNA levels were abundantly expressed in rejecting EMB (ISHLT rejection grade>1R) compared with EMB without histological evidence of myocardial damage (ISHLT rejection grade 0R-1R; p=0.003), no association with rejection or non-responsiveness was found for the FOXP3 mRNA levels in the peripheral blood. Thus, in contrast to intragraft FOXP3 gene expression, the peripheral FOXP3 mRNA levels lack correlation with anti-donor immune responses in the graft, and, consequently, FOXP3 does not appear to be a potential candidate gene for non-invasive diagnosis of non-responsiveness or rejection.

Intragraft FOXP3 mRNA expression reflects antidonor immune reactivity in cardiac allograft patients.

BACKGROUND: Regulatory FOXP3+ T cells control immune responses of effector T cells. However, whether these cells regulate antidonor responses in the graft of cardiac allograft patients is unknown. Therefore, we analyzed the gene expression profiles of regulatory and effector T-cell markers during immunological quiescence and acute rejection. METHODS: Quantitative real-time polymerase chain reaction was used to analyze mRNA expression levels in time-zero specimens (n=24) and endomyocardial biopsies (EMB; n=72) of cardiac allograft patients who remained free from rejection (nonrejectors; n=12) and patients with at least one histologically proven acute rejection episode (rejectors; International Society for Heart and Lung Transplantation [ISHLT] rejection grade>2; n=12). RESULTS: For all analyzed regulatory and effector T-cell markers, mRNA expression levels were increased in biopsies taken after heart transplantation compared with those in time-zero specimens. Posttransplantation, the FOXP3 mRNA levels were higher in EMB assigned to a higher ISHLT rejection grade than the biopsies with grade 0: the highest mRNA levels were detected in the rejection biopsies (rejection grade>2; P=0.003). In addition, the mRNA levels of CD25, glucocorticoid-induced TNF receptor family-related gene, cytotoxic T lymphocyte-associated antigen 4, interleukin-2, and granzyme B were also significantly higher in rejecting EMB than in nonrejecting EMB (rejection grade

Donor-specific cytotoxic hyporesponsiveness associated with high interleukin-10 messenger RNA expression in cardiac allograft patients.

BACKGROUND: After transplantation, CD4+CD25+FOXP3+ and interleukin (IL) 10-producing regulatory cells might regulate immune responses toward donor antigens. In this study, we determined whether cardiac allograft recipients show donor-specific hyporesponsiveness and studied the underlying mechanisms. METHODS: We analyzed the donor-specific T-cell responses by mixed lymphocyte reactions and limiting dilution assays to define whether cardiac allograft recipients (n = 21) show proliferative and cytotoxic hyporesponsiveness to donor antigens long after transplantation (range, 1.5-7 years). The mechanisms controlling immune responses, that is, FOXP3+/GITR+ T cells, and IL-10-producing cells, were studied by quantitative real-time polymerase chain reaction. RESULTS: In the presence of a proliferative response to donor antigens, no cytotoxic responsiveness could be measured in a number of patients in the absence (73%) and presence of exogenous IL-2 (29%), IL-15 (31%), and IL-15 plus IL2Ralpha blockade (88%). Overall, the cytotoxic response to donor cells was significantly lower than the reactivity to third-party cells after the addition of IL-2 (p = 0.004) and IL-15 plus IL2Ralpha blockade (p < 0.001). After donor stimulation, the peripheral blood mononuclear cells expressed higher messenger RNA (mRNA) levels of IL-10, but not of FOXP3 or GITR, than after third-party stimulation (p = 0.003). Moreover, the IL-10 mRNA expression was inversely correlated with the donor-specific cytotoxic responsiveness (p = 0.01). CONCLUSIONS: A significant proportion of patients showed donor-specific cytotoxic hyporesponsiveness long after heart transplantation, which was associated with high mRNA levels of IL-10 but not of FOXP3 or GITR. This observation suggests that IL-10-producing cells participate in the donor-specific cytotoxic hyporeactivity.

Impaired circulating dendritic cell reconstitution identifies rejecting recipients after clinical heart transplantation independent of rejection therapy.

OBJECTIVE: Dendritic cell (DC) mediated allo-antigen presentation to host antigen specific T-lymphocytes initiates acute allograft rejection. We investigated peripheral blood DC (PBDC) incidence and DC subset reconstitution in relation to histological diagnosis of acute cellular rejection (AR) and administration of rejection therapy after clinical heart transplantation (post-HTx). METHODS: Venous blood from 20 HTx recipients under standard immunosuppression was collected during serial endomyocardial biopsy (EMB) prior to administration of rejection therapy in a 9-month follow-up post-HTx. Echocardiographic assessment of allograft function during EMB was performed to distinguish clinical necessity for rejection therapy within histologically rejecting patients (R). Myeloid (mDC) and plasmacytoid (pDC) subsets identified by flow-cytometry were analysed for different ISHLT rejection grades. Circulating PBDC incidence and mDC/pDC ratio were compared sequentially between non-rejecting (NR) recipients and R patients treated (3A(+)) or not-treated (3A(-)) with rejection therapy during follow-up. RESULTS: Eleven samples from biopsy-proven AR episodes (AR(+): ISHLT>or=3) were compared to 89 samples from non-rejection episodes (AR(-): ISHLT grade 0, n=52; grade 1, n=29; grade 2, n=8). We observed an inverse correlation of mDCs (P<0.05) but not pDCs with increasing rejection grade. PBDC incidence and mDC/pDC ratio were low in blood samples obtained during AR (P<0.05 and P<0.01, respectively). Both PBDCs and mDC/pDC ratio decreased during each AR episode (P<0.05). Comparison of 3A(+) and 3A(-) rejectors with NR patients after 12 weeks post-HTx revealed lower PBDC incidence (P<0.01) and mDC/pDC ratio (P<0.05) for R patients, independent of rejection therapy. CONCLUSIONS: Defective DC subset reconstitution by dendritic cell profiling identifies patients at risk for AR after 3 months post-HTx. This finding may contribute to further optimization of immunosuppressive treatment strategies after clinical heart transplantation.

Preferential depletion of blood myeloid dendritic cells during acute cardiac allograft rejection under controlled immunosuppression.

Allo-Ag presentation to Ag-specific T-lymphocytes by donor or recipient dendritic cells (DCs) induces acute rejection (AR) after solid organ transplantation. It is postulated that myeloid (mDC) and plasmacytoid (pDC) subsets circulate differentially between bone marrow, heart and lymphoid tissues after cardiac transplantation (HTx). We investigated peripheral blood DC subset distribution, maturation and lymphoid homing properties in relation to endomyocardial biopsy (EMB) rejection grade after clinical HTx. Twenty-one HTx recipients under standard immunosuppression were studied in a 9-month follow-up. mDC and pDC numbers were analyzed by flow cytometry in fresh venous whole blood samples collected during the EMB procedures and before histological diagnosis of AR. Subsets were further characterized for maturation marker CD83 and lymphoid homing chemokine receptor CCR7. Although numbers of both DC subsets remained low for the whole post-HTx period, we observed a negative association of mDCs with rejection grade. Repeated measurements analysis revealed that only mDCs decreased during AR episodes. Rejectors had lower mDC numbers after a 3-month follow-up compared to nonrejectors. Furthermore, patients during AR exhibited low proportions of mDCs positive for CD83 or CCR7. These findings suggest peripheral blood mDC depletion in association with selective lymphoid homing of this subset during AR after clinical HTx.

CT and myasthenia gravis: correlation between mediastinal imaging and histopathological findings.

The surgical strategy in patients with myasthenia gravis (MG) is influenced by the suspicion of thymoma based on mediastinal imaging. Aim of this retrospective study was to analyse the accuracy of CT of the mediastinum in predicting the histological findings in patients with MG referred for thymectomy. Thirty-four CT-scans of MG patients referred for thymectomy between October 1989 and October 2003 were retrospectively evaluated by three cardio-thoracic surgeons and three radiologists. Data were analysed by Kappa statistics to judge inter-observer variance and were compared to the histopathological findings to determine predictive value. Observer agreement among the radiologists was fair (Kappa=0.28) and among the cardio-thoracic surgeons slight (Kappa=0.08). The average negative predictive value of no thymoma on CT was 91% (range 78-100%). The average positive predictive of thymoma on CT value was only 39% (range 29-58%). The average sensitivity of CT imaging in the study population was 75% (range 25-100%) and the average specificity was 62% (range 42-81%). In patients with MG undergoing thymectomy, CT is helpful in detecting thymoma, but the high inter-observer variation indicates that it remains difficult to distinguish lymphoid follicular hyperplasia from thymoma. This will influence the surgical strategy in patients with myasthenia gravis.

Peripheral blood dendritic cells in human end-stage heart failure and the early post-transplant period: evidence for systemic Th1 immune responses.

OBJECTIVES: Dendritic cells (DCs) are antigen presenting cells that play a central role in inflammation, allograft rejection and immune tolerance. Myeloid (mDC) and plasmacytoid (pDC) subsets regulate immune reactions by polarising naive T-helper cells into a Th1 or Th2 response, respectively. In this study we examined total peripheral blood DCs, mDC and pDC subsets in chronic heart failure (CHF) and clinical heart transplantation (HTx). METHODS: We compared 16 heart transplant patients before and after HTx to 14 healthy controls. Whole blood was collected pre-HTx and 1-week post-HTx from patients and at corresponding time-points from controls. All patients received induction and maintenance immunosuppression post-HTx. mDCs and pDCs were measured by flow cytometry and were further characterised for maturation and homing potential to the secondary lymphoid organs with CD83 and CCR7, respectively. Data were expressed as absolute numbers/microl whole blood, percentage (%) mDC or pDC of total blood DCs and % positive DCs for CD83 and CCR7. RESULTS: CHF patients had more peripheral blood DCs compared to controls (P<0.01) while only the mDC fraction was increased compared to controls (P=0.01). Percentage CD83(+) and CCR7(+) mDCs was also higher than control levels (P<0.05). One week post-HTx, total DCs, mDCs and pDCs decreased below controls (P<0.001). At the same time % mDCs in peripheral blood increased markedly compared to CHF and control levels (P<0.001). The %CD83(+) mDC, %CD83(+) pDC and %CCR7(+) mDC also returned to control levels and only %CCR7(+) pDC decreased below control levels (P=0.005). CONCLUSIONS: Total peripheral blood DCs are elevated during CHF due to an increase in the mature fraction of the mDC subset suggesting a possible Th1 response in end-stage heart failure. The decrease in total DCs and mature mDCs and pDCs seen post-HTx, probably reflects immunological quiescence through adequate immunosuppression. Peripheral blood DC monitoring may provide a new insight into mechanisms of heart failure and allograft rejection by safe weaning from immunosuppression after clinical HTx.

Abdominal aortic aneurysms after heart transplantation.

BACKGROUND: In recent years abdominal aortic aneurysms were diagnosed in several heart transplant recipients at our center. Only case reports or small series have been reported previously and little is known about abdominal aortic aneurysms after heart transplantation. Therefore, the goals of this study were to estimate the incidence of this condition after heart transplantation, to identify risk factors for its development, and to assess its clinical consequences. METHODS: Our investigation was a retrospective, single-center cohort study of 368 consecutive patients transplanted between 1984 and 1999. RESULTS: During a mean follow-up of 75 +/- 49 months, 37 of the 368 (10%) transplant recipients and 36 of 202 (18%) of the sub-group with a history of ischemic heart disease were found to have an abdominal aortic aneurysm. All patients were male, and all except 1 had a history of ischemic heart disease. A history of ischemic heart disease prior to heart transplantation was the sole independent risk factor for developing an aneurysm by multivariate analysis. Aneurysm-related events occurred earlier and more frequently in the 7 transplant recipients who already had a dilated abdominal aorta prior to transplantation. The abdominal aortic aneurysm was the direct or indirect cause of death in at least 9 patients. CONCLUSIONS: Abdominal aortic aneurysms are relatively frequent after heart transplantation, occur at a younger age than in the general population, and have serious clinical consequences. Close ultrasonographic follow-up of patients with a history of ischemic heart disease or with an abnormal abdominal aorta prior to heart transplantation seems indicated.

Catheter-based intramyocardial injection of autologous skeletal myoblasts as a primary treatment of ischemic heart failure: clinical experience with six-month follow-up.

OBJECTIVES: We report on the procedural and six-month results of the first percutaneous and stand-alone study on myocardial repair with autologous skeletal myoblasts. BACKGROUND: Preclinical studies have shown that skeletal myoblast transplantation to injured myocardium can partially restore left ventricular (LV) function. METHODS: In a pilot safety and feasibility study of five patients with symptomatic heart failure (HF) after an anterior wall infarction, autologous skeletal myoblasts were obtained from the quadriceps muscle and cultured in vitro for cell expansion. After a culturing process, 296 +/- 199 million cells were harvested (positive desmin staining 55 +/- 30%). With a NOGA-guided catheter system (Biosense-Webster, Waterloo, Belgium), 196 +/- 105 million cells were transendocardially injected into the infarcted area. Electrocardiographic and LV function assessment was done by Holter monitoring, LV angiography, nuclear radiography, dobutamine stress echocardiography, and magnetic resonance imaging (MRI). RESULTS: All cell transplantation procedures were uneventful, and no serious adverse events occurred during follow-up. One patient received an implantable cardioverter-defibrillator after transplantation because of asymptomatic runs of nonsustained ventricular tachycardia. Compared with baseline, the LV ejection fraction increased from 36 +/- 11% to 41 +/- 9% (3 months, p = 0.009) and 45 +/- 8% (6 months, p = 0.23). Regional wall analysis by MRI showed significantly increased wall thickening at the target areas and less wall thickening in remote areas (wall thickening at target areas vs. 3 months follow-up: 0.9 +/- 2.3 mm vs. 1.8 +/- 2.4 mm, p = 0.008). CONCLUSIONS: This pilot study is the first to demonstrate the potential and feasibility of percutaneous skeletal myoblast delivery as a stand-alone procedure for myocardial repair in patients with post-infarction HF. More data are needed to confirm its safety.

Differential intragraft cytokine messenger RNA profiles during rejection and repair of clinical heart transplants. A longitudinal study.

After clinical heart transplantation, ischemia, acute rejection, and repair mechanisms can trigger the up-regulation of cytokines. To investigate the cytokine profile early after transplantation, we monitored messenger RNA (mRNA) expression levels of tumor necrosis factor-alpha (TNF-alpha), monocyte chemoattractant protein-1 (MCP-1), transforming growth factor-beta (TGF-beta), platelet-derived growth factor-A (PDGF-A), and basic fibroblast growth factor (bFGF) by reverse transcriptase-polymerase chain reaction (RT-PCR) in serial endomyocardial biopsies ( n=123) from 16 cardiac allograft recipients during the first 3 post-operative months. In the first month, mRNA expression levels of MCP-1, TNF-alpha, TGF-beta, and bFGF were significantly higher than in the period thereafter (acute rejection episodes excluded). Acute rejection (International Society for Heart and Lung Transplantation (ISHLT) rejection grade >2) was strongly associated with the level of TNF-alpha mRNA. After acute rejection episodes, rising mRNA expression levels of PDGF-A and bFGF were found. The association between TNF-alpha mRNA and acute rejection reflects the importance of this cytokine in allogeneic responses. Elevated growth factor expression levels indicate repair responses after tissue damage due to either the transplantation procedure (surgery, ischemia, reperfusion) or acute allograft rejection.

Sequential monitoring of intragraft cytokine mRNA expression in relation to diastolic left ventricular wall thickness and function early after heart transplantation.

Because production of immune regulatory proteins may play a role in early graft dysfunction after heart transplantation, we analyzed whether intragraft cytokine messenger RNA (mRNA) expression levels are associated with diastolic left ventricular function in cardiac allografts. We intensively monitored 16 cardiac allograft recipients during the first 3 months after transplantation. The mRNA expression levels of tumor necrosis factor (TNF-alpha), monocyte chemoattractant protein-1 (MCP-1), transforming growth factor (TGF-beta), platelet derived growth factor (PDGF-A), and basic fibroblast growth factor (bFGF) were measured in endomyocardial biopsies (n = 123) by quantitative RT-PCR. To determine diastolic allograft function, concurrent M-mode and two-dimensional Doppler echocardiograms were analyzed for the following parameters: left ventricular total wall thickness, maximal early and atrial mitral flow velocity, deceleration time of maximal early mitral flow velocity, and isovolumetric relaxation period. During the first 3 months post-transplant an overall decrease in mRNA expression levels of almost all measured cytokines was observed, which paralleled an improvement in diastolic left ventricular wall thickness and function. However, no straightforward relationship could be found between a specific cytokine mRNA expression pattern and the studied echocardiographic parameters. Our data suggest that the improvement in diastolic left ventricular function is associated with a general reduction of inflammation within the allograft, rather than related to a specific cytokine expression pattern.

Effect of HLA-DR matching on acute rejection after clinical heart transplantation might be influenced by an IL-2 gene polymorphism.

BACKGROUND: To examine whether genetic factors are involved in the development of acute rejection (AR), we investigated a (CA)m(CT)n repeat in the 3'-flanking region of the interleukin (IL)-2 gene. METHOD: We genotyped 290 heart transplant recipients with and without AR (International Society for Heart and Lung Transplantation criteria > or =3A) and 101 controls. RESULTS: The frequency of allele 135 of the repeat and its genotype distribution (carriers/noncarriers) were significantly associated with freedom from AR (P=0.03 and P=0.02, respectively). We also found interaction between allele 135 and HLA-DR matching. More carriers of allele 135 with no or one mismatch remained free from AR compared to patients without the allele (P=0.01). This was not found in the HLA-DR group with two mismatches. CONCLUSION: HLA-DR matching might only be effective in reducing AR after heart transplantation in recipients who carry allele 135 of the (CA)m(CT)n repeat in the 3'-flanking region of the IL-2 gene.