Urokinase plasminogen activator protects cardiac myocytes from oxidative damage and apoptosis via hOGG1 induction.

The role of uPA in tissue remodeling and cell migration is already well established. In addition, uPA was reported to stabilize p53, a key cell cycle control, DNA repair and apoptosis initiation protein. We aimed to determine the role of uPA-uPAR signaling towards cell survival or apoptosis in human adult cardiac myocytes (HACM). HACM were stimulated with uPA and DNA damage was inflicted by incubating cells with 200 µM H2O2. To analyze for apoptotic cells we applied TUNEL staining. Oxidative damage foci were analyzed by staining for 8-oxoguanine base pairs. In vivo qPCR analysis from RNA extracted from failing human hearts demonstrated a close relation of uPA with apoptosis and the p53 pathway. Furthermore, we observed a close correlation of uPA and p53 protein in homogenized tissue lysates. In vitro studies revealed that uPA preincubation protected HACM from oxidative damage induced cell death and reduced oxidative damage foci. uPA protection is independent of its catalytic activity, as the amino terminal fragment of uPA showed similar protection. A key enzyme for repairing oxidative DNA damage is the p53 target hOGG1. We found a significant increase of hOGG1 after pretreatment of HACM with uPA. Knockdown of hOGG1 completely abrogated the protective effect of uPA. We conclude that uPA might have a tissue protective role in human hearts besides its role in tissue remodeling. Tissue protection is mediated by the DNA repair protein hOGG1. This might be beneficial during tissue remodeling and thus could be a target for therapeutic approaches in the diseased heart.

Components of the interleukin-33/ST2 system are differentially expressed and regulated in human cardiac cells and in cells of the cardiac vasculature.

Interleukin-33 (IL-33) is a recently described member of the IL-1 family of cytokines, which was identified as a ligand for the ST2 receptor. Components of the IL-33/ST2 system were shown to be expressed in normal and pressure overloaded human myocardium, and soluble ST2 (sST2) has emerged as a prognostic biomarker in myocardial infarction and heart failure. However, expression and regulation of IL-33 in human adult cardiac myocytes and fibroblasts was not tested before. In this study we found that primary human adult cardiac fibroblasts (HACF) and human adult cardiac myocytes (HACM) constitutively express nuclear IL-33 that is released during cell necrosis. Tumor necrosis factor (TNF)-α, interferon (IFN)-γ and IL-1ß significantly increased both IL-33 protein and IL-33 mRNA expression in HACF and HACM as well as in human coronary artery smooth muscle cells (HCASMC). The nuclear factor-κB (NF-κB) inhibitor dimethylfumarate inhibited TNF-α- and IL-1ß-induced IL-33 production as well as nuclear translocation of p50 and p65 NF-κB subunits in these cells. Mitogen-activated protein/extracellular signal-regulated kinase inhibitor U0126 abrogated TNF-α-, IFN-γ-, and IL-1ß-induced and Janus-activated kinase inhibitor I reduced IFN-γ-induced IL-33 production. We detected IL-33 mRNA in human myocardial tissue from patients undergoing heart transplantation (n=27) where IL-33 mRNA levels statistically significant correlated with IFN-γ (r=0.591, p=0.001) and TNF-α (r=0.408, p=0.035) mRNA expression. Endothelial cells in human heart expressed IL-33 as well as ST2 protein. We also reveal that human cardiac and vascular cells have different distribution patterns of ST2 isoforms (sST2 and transmembrane ST2L) mRNA expression and produce different amounts of sST2 protein. Both human macrovascular (aortic and coronary artery) and heart microvascular endothelial cells express specific mRNA for both ST2 isoforms (ST2L and sST2) and are a source for sST2 protein, whereas cardiac myocytes, cardiac fibroblasts and vascular SMC express only minor amounts of ST2 mRNA and do not secrete detectable amounts of sST2 antigen. In accordance with the cellular distribution of ST2 receptor, human cardiac fibroblasts and myocytes as well as HCASMC did not respond to treatment with IL-33, as recombinant human IL-33 did not induce NF-κB p50 and p65 subunits nuclear translocation or increase IL-6, IL-8, and monocyte chemoattractant protein (MCP-1) level in HACF, HACM and HCASMC. In summary, we found that endothelial cells seem to be the source of sST2 and the target for IL-33 in the cardiovascular system. IL-33 is expressed in the nucleus of human adult cardiac fibroblasts and myocytes and released during necrosis. Proinflammatory cytokines TNF-α, IFN-γ and IL-1ß increase IL-33 in these cells in vitro, and IL-33 mRNA levels correlated with TNF-α and IFN-γ mRNA expression in human myocardial tissue.

Induction therapy in heart transplantation: where are we now?

Although induction therapy has been used in heart transplantation for many years, its role has not been fully elucidated. Early safety concerns relating to OKT3 or intensive lymphocyte-depleting regimens have largely been addressed by modern induction protocols using rabbit antithymocyte globulin (rATG [Thymoglobuline(®) or ATG-Fresenius]) and interleukin-2 receptor antagonist (IL-2RA) agents, but although the number of randomized controlled studies has expanded there are still gaps in the evidence base. Rejection prophylaxis may be somewhat more effective with rATG than IL-2RA agents, but this has not been proven conclusively. Administration of induction therapy to support delayed introduction of calcineurin inhibitors in patients at risk of renal dysfunction is relatively well documented and widely used. Increasingly, it is recognized that sensitized patients and individuals with primary graft function are suitable candidates for induction therapy, and the possibility that rATG may inhibit cardiac allograft vasculopathy is also of considerable interest. Until the question of whether rATG is associated with increased risk of infection, routine prophylaxis is advisable. IL-2RA induction has an excellent safety profile. Dosing rATG according to lymphocyte count reduces cumulative dose without compromising efficacy. Further controlled trials are required to determine when and how to deploy induction most effectively following heart transplantation.

Current strategies and future trends in immunosuppression after heart transplantation.

PURPOSE OF REVIEW: Current immunosuppressive drugs have provided excellent outcomes after heart transplantation. However, more patients suffer from long-term complications of these drugs. A series of prospective randomized trials has been conducted and has offered disparate results. This report reviews the challenges of immunosuppressive therapy during the past decade, describes recent reports and explores potential future trends in immunosuppressive protocols in heart transplantation. RECENT FINDINGS: The traditional combination of cyclosporine, azathioprine and steroids has been changed to tacrolimus (Tac) or cyclosporine in combination with mycophenolate mofetil (MMF) and steroids due to the results of several trials. The use of mammalian target of rapamycin inhibitors in combination with Tac or cyclosporine A has not shown a clear benefit compared with MMF. All different combinations have shown some positive effects counteracted by side-effects and negative synergism of combinations. Future protocols need to be adapted according to individual patient's needs and risks. SUMMARY: The changing population of heart transplantation patients has become older and sicker. Immunosuppression strategies should be developed for each patient based on their risk for rejection and their risk for developing important complications of immunosuppressive therapy.

Is induction therapy still needed in heart transplantation?

PURPOSE OF REVIEW: Induction therapy has continued to be a subject of controversy in heart transplantation for more than 20 years. The benefits and safety of this approach as a universal strategy have been studied during the past decade with disparate results. This report reviews the challenges in induction therapy during the past decade, describes the recent reports, and explores the pitfalls and benefits of using this strategy in heart transplantation. RECENT FINDINGS: Recent developments in induction therapy have paved the way for new approaches how to use antibodies in this setting. Alemtuzumab, a new monoclonal antibody against the CD52 antigen on mature lymphocytes, was successfully tested in cardiac transplant patients, showing significantly less rejection incidence with low infection rates. Long-term examinations of antithymocyte globulin induction showed lower rejection rates and no increase of posttransplantation lymphoproliferative disease risk. However, higher infection rates were found. Patient groups have been selected who might have particular benefit form induction therapy. These groups consist of patients with a high risk to develop cellular or antibody rejection, patients with impaired renal function in who introduction of calcineurin inhibitor therapy should be delayed and patients with calcineurin inhibitor-free therapy. SUMMARY: Induction therapy still has its place in the immunosuppressive armamentarium after cardiac transplantation. New antibody generations and the selection of special patient groups demonstrate that induction therapy is effective and well tolerated in its use.

Donor serum SMARCAL1 concentrations predict primary graft dysfunction in cardiac transplantation.

BACKGROUND: Primary graft dysfunction (PGD) is a life-threatening complication in cardiac transplantation. A sensitive, specific, and easily measurable predictor in donors could facilitate PGD prevention. METHODS AND RESULTS: SMARCAL1 is a matrix-associated regulator of chromatin with helicase and ATPase activities, and its serum concentrations were significantly increased in a targeted protein array in donors whose grafts developed PGD. Therefore, this study analyzed SMARCAL1 serum concentrations by ELISA in 336 heart donors before and after aortic cross-clamping (ACC) and in recipients at 10, 30, and 60 minutes reperfusion. Demographic and hemodynamic parameters of donors and recipients as well as transplant procedure characteristics were documented. PGD (n=68) was defined as ventricular dilation and hypocontractility associated with systolic blood pressure <90 mm Hg, pulmonary capillary wedge pressure >20 mm Hg, and decreased mixed venous oxygen saturation necessitating mechanical circulatory support. SMARCAL1 serum protein concentration was significantly increased only before and after ACC in donors (P<0.0001) whose grafts developed PGD compared to those who did not. In receiver operating characteristic curve analysis, SMARCAL1 serum concentration at a cut-off level of > or =1.25 ng/mL before ACC in donors predicted PGD (P<0.0001, AUC=0.988, OR=17.050, 95% CI=5.200 to 55.901) with 96% sensitivity and 88% specificity. SMARCAL1 serum concentrations <1.25 ng/mL in donors before ACC resulted in 97% PGD-free outcome and SMARCAL1 concentrations > or =1.25 resulted in 83% PGD occurrence. CONCLUSIONS: Donor serum SMARCAL1 may serve as a specific, sensitive, and noninvasive predictive marker in the assessment of cardiac graft quality.

An integrated molecular diagnostic report for heart transplant biopsies using an ensemble of diagnostic algorithms.

BACKGROUND: We previously reported a microarray-based diagnostic system for heart transplant endomyocardial biopsies (EMBs), using either 3-archetype (3AA) or 4-archetype (4AA) unsupervised algorithms to estimate rejection. In the present study we examined the stability of machine-learning algorithms in new biopsies, compared 3AA vs 4AA algorithms, assessed supervised binary classifiers trained on histologic or molecular diagnoses, created a report combining many scores into an ensemble of estimates, and examined possible automated sign-outs. METHODS: We studied 889 EMBs from 454 transplant recipients at 8 centers: the initial cohort (N = 331) and a new cohort (N = 558). Published 3AA algorithms derived in Cohort 331 were tested in Cohort 558, the 3AA and 4AA models were compared, and supervised binary classifiers were created. RESULTS: A`lgorithms derived in Cohort 331 performed similarly in new biopsies despite differences in case mix. In the combined cohort, the 4AA model, including a parenchymal injury score, retained correlations with histologic rejection and DSA similar to the 3AA model. Supervised molecular classifiers predicted molecular rejection (areas under the curve [AUCs] >0.87) better than histologic rejection (AUCs <0.78), even when trained on histology diagnoses. A report incorporating many AA and binary classifier scores interpreted by 1 expert showed highly significant agreement with histology (p < 0.001), but with many discrepancies, as expected from the known noise in histology. An automated random forest score closely predicted expert diagnoses, confirming potential for automated signouts. CONCLUSIONS: Molecular algorithms are stable in new populations and can be assembled into an ensemble that combines many supervised and unsupervised estimates of the molecular disease states.

Exploring the cardiac response to injury in heart transplant biopsies.

BACKGROUND: Because injury is universal in organ transplantation, heart transplant endomyocardial biopsies present an opportunity to explore response to injury in heart parenchyma. Histology has limited ability to assess injury, potentially confusing it with rejection, whereas molecular changes have potential to distinguish injury from rejection. Building on previous studies of transcripts associated with T cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR), we explored transcripts reflecting injury. METHODS: Microarray data from 889 prospectively collected endomyocardial biopsies from 454 transplant recipients at 14 centers were subjected to unsupervised principal component analysis and archetypal analysis to detect variation not explained by rejection. The resulting principal component and archetype scores were then examined for their transcript, transcript set, and pathway associations and compared to the histology diagnoses and left ventricular function. RESULTS: Rejection was reflected by principal components PC1 and PC2, and by archetype scores S2TCMR, and S3ABMR, with S1normal indicating normalness. PC3 and a new archetype score, S4injury, identified unexplained variation correlating with expression of transcripts inducible in injury models, many expressed in macrophages and associated with inflammation in pathway analysis. S4injury scores were high in recent transplants, reflecting donation-implantation injury, and both S4injury and S2TCMR were associated with reduced left ventricular ejection fraction. CONCLUSION: Assessment of injury is necessary for accurate estimates of rejection and for understanding heart transplant phenotypes. Biopsies with molecular injury but no molecular rejection were often misdiagnosed rejection by histology.TRAIL REGISTRATION. ClinicalTrials.gov NCT02670408FUNDING. Roche Organ Transplant Research Foundation, the University of Alberta Hospital Foundation, and Alberta Health Services.

Immunosuppressive therapy in older cardiac transplant patients.

Cardiac transplantation has become an established intervention for end-stage heart disease. Clinical outcomes in older cardiac transplant patients have improved over the last decade and are almost similar to those in younger patients. Nevertheless, morbidity and mortality due to infections, cancer and chronic allograft vasculopathy remain problematic. On the other hand, older transplant patients seem to have lower incidences of acute rejection episodes than younger patients. Conventional immunosuppression with calcineurin-inhibiting drugs, azathioprine and corticosteroids is responsible for a number of adverse effects. Although these adverse effects can also be seen in younger patients, tolerance to these agents seems to decrease with increasing age. In particular, diabetes mellitus, osteoporosis and chronic renal insufficiency are associated with higher morbidity and mortality in older cardiac transplant patients. As the elderly become an ever-increasing segment of the cardiac transplant population, new and innovative immunosuppressive strategies will have to be developed and applied.Currently, the availability of new immunosuppressive drugs means more individualised immunosuppressive protocols can be used. New antibodies for induction therapy, a choice between ciclosporin and tacrolimus, and the advent of mycophenolate mofetil as well as proliferation signal inhibitors (everolimus, sirolimus) have changed immunosuppressive protocols dramatically. Therefore, a generalised protocol for all patients has been replaced by individualised immunosuppression depending on the patient group. Moreover, protocols can be modified during follow-up depending on the individual patient's requirements and problems. Hypertension and hyperlipidaemia could be influenced by the selection of tacrolimus over ciclosporin, and weaning of corticosteroids might have a positive impact on osteoporosis or diabetes. There is also no clear evidence that tacrolimus is associated with a higher risk for new onset of diabetes. Chronic renal insufficiency can be managed with calcineurin inhibitor-free immunosuppression consisting of mycophenolate mofetil and proliferation signal inhibitors. Both everolimus and sirolimus also seem to have a protective effect against the onset of graft vasculopathy and some sorts of cancer after cardiac transplantation. As a general rule, however, older cardiac transplant patients should be treated with lower doses and fewer immunosuppressive drugs to avoid over-immunosuppression.

Impact of Rabbit Antithymocyte Globulin Dose on Long-term Outcomes in Heart Transplant Patients.

BACKGROUND: Optimal dosing strategies have not been established for rabbit antithymocyte globulin (rATG) after heart transplantation, and there is currently wide variability in rATG regimens with respect to both dose and duration. METHODS: In a retrospective, single-center analysis, 523 patients undergoing heart transplantation during 1996 to 2009 were stratified by cumulative rATG dose: less than 4.5 mg/kg (group A), 4.5 to 7.5 mg/kg (group B) or greater than 7.5 mg/kg (group C). RESULTS: Survival at 1 year after transplantation was 80% in group A, 90% in group B, and 88% in group C (P = 0.062). Incidence of acute rejection per 1000 patient-years was significantly higher in group A (hazards ratio [HR], 54.8; 95% confidence interval [95% CI], 33.9-83.8) compared to groups B (19.6; 95% CI, 11.4-31.4) and C (23.6; 95% CI, 17.5-31.3). Incidence of severe infection 10 years after transplantation was higher in group C (45%) than groups A (37%) or B (23%) (P < 0.001); cytomegalovirus infection rates were 35%, 20% and 23%, respectively (P = 0.009). Multivariable Cox regression showed an HR of 0.51 (95% CI, 0.25-1.02) for acute rejection with group B versus group A, and 0.54 (95% CI, 0.33-0.88; P = 0.013) for severe infection. The rate of malignancy per 1000 patient-years was higher in groups B (13.85) and C (14.95) than group A (7.83). CONCLUSIONS: These retrospective data suggest that a cumulative rATG dose of 4.5 to 7.5 mg/kg may offer a better risk-benefit ratio than lower or higher doses, with acceptable rates of infection and posttransplant malignancy. Prospective trials are needed.

Detection of alloantibody-mediated complement activation: A diagnostic advance in monitoring kidney transplant rejection?

OBJECTIVE: Antibody-mediated rejection (ABMR) is an important cause of kidney allograft injury. In the last two decades, detection of complement split product C4d along transplant capillaries, a footprint of antibody-mediated classical complement activation, has evolved as a useful diagnostic marker of ABMR. While it was recognized that ABMR may occur also in the absence of C4d, numerous studies have shown that C4d deposition may indicate a more severe rejection phenotype associated with poor graft survival. Such studies suggest a possible diagnostic benefit of ex vivo monitoring the complement-activating capability of circulating alloantibodies. DESIGN AND METHODS: We reviewed the literature between 1993 and 2015, focusing on in vivo (biopsy work-up) and in vitro detection (modified bead array technology) of HLA antibody-triggered classical complement activation in kidney transplantation. RESULTS: Precise HLA antibody detection methods, in particular Luminex-based single antigen bead (SAB) assays, have provided a valuable basis for the design of techniques for in vitro detection of HLA antibody-triggered complement activation reflected by C1q, C4 or C3 split product deposition to the bead surface. Establishing such assays it was recognized that deposition of complement products to SAB, which critically depends on antibody binding strength, may be a cardinal trigger of the prozone effect, a troublesome in vitro artifact caused by a steric interference with IgG detection reagents. False-low IgG results, especially on SAB with extensive antibody binding, have to be considered when interpreting studies analyzing the diagnostic value of complement in relation to standard IgG detection. Levels of complement-fixing donor-specific antibodies (DSA) were shown to correlate with the results of standard crossmatch tests, suggesting potential application for crossmatch prediction. Moreover, while the utility of pre-transplant complement detection, at least in crossmatch-negative transplant recipients, is controversially discussed, a series of studies have shown that the appearance of post-transplant complement-fixing DSA may be associated with C4d deposition in transplant capillaries and a particular risk of graft failure. CONCLUSIONS: The independent value of modified single antigen bead assays, as compared to a careful analysis of standard IgG detection, which may be affected considerably by complement dependent artifacts, needs to be clarified. Whether they have the potential to improve the predictive accuracy of our current diagnostic repertoire warrants further study.

Levosimendan exerts anti-inflammatory effects on cardiac myocytes and endothelial cells in vitro.

Levosimendan is a positive inotropic drug for the treatment of acute decompensated heart failure (HF). Clinical trials showed that levosimendan was particularly effective in HF due to myocardial infarction. Myocardial necrosis induces a strong inflammatory response, involving chemoattractants guiding polymorphonuclear neutrophils (PMN) into the infarcted myocardial tissue. Our aim was to examine whether levosimendan exhibits anti-inflammatory effects on human adult cardiac myocytes (HACM) and human heart microvascular endothelial cells (HHMEC). Cardiac myocytes and endothelial cells were stimulated with interleukin-1ß (IL)-1ß (200 U/ml) and treated with levosimendan (0.1-10 µM) for 2-48 hours. IL-1ß strongly induced expression of IL-6 and IL-8 in HACM and E-selectin and intercellular adhesion molecule-1 (ICAM-1) in HHMEC and human umbilical vein endothelial cells (HUVEC). Treatment with levosimendan strongly attenuated IL-1ß-induced expression of IL-6 and IL-8 in HACM as well as E-selectin and ICAM-1 in ECs. Levosimendan treatment further reduced adhesion of PMN to activated endothelial cells under both static and flow conditions by approximately 50 %. Incubation with 5-hydroxydecanoic acid, a selective blocker of mitochondrial ATP-dependent potassium channels, partly abolished the above seen anti-inflammatory effects. Additionally, levosimendan strongly diminished IL-1ß-induced reactive oxygen species and nuclear factor-κB (NF-κB) activity through inhibition of S536 phosphorylation. In conclusion, levosimendan exhibits anti-inflammatory effects on cardiac myocytes and endothelial cells in vitro. These findings could explain, at least in part, the beneficial effects of levosimendan after myocardial infarction.

Lack of donor and recipient age interaction in cardiac transplantation.

BACKGROUND: The proportion of older donors and recipients is constantly rising in heart transplantation (HTX). The impact of age on different outcomes after HTX has been studied; however, effects of interaction between donor and recipient age remain elusive. METHODS: This retrospective cohort study comprised 1,190 patients who underwent HTX between 1984 and 2011 at the Medical University Vienna. Multivariable models consisted of a basic set that included donor age, recipient age, and transplant eras and were adjusted for 2 sets of 6 possible confounders and 3 mediator variables. Cox models were used to estimate the risk of death. To search for age-related effects on the development of cardiac allograft vasculopathy (CAV), we applied cause-specific Cox models and proportional sub-distribution hazard models for competing risk data. RESULTS: Survival was 80%, 77%, 69%, and 56% after 1, 2, 5, and 10 years, respectively. Donor age (hazard ratio [HR], 1.1; 95% confidence interval [CI], 1.0-1.2), recipient age (HR, 1.1; 95% CI, 1.0-1.2), admission from intensive care unit to HTX (HR, 1.5; 95% CI, 1.2-1.9), and diabetes (HR, 1.4; 95% CI, 1.1-1.7) were identified as significant independent risk factors for death. Significant risk factors for CAV were donor age (HR, 1.4; 95% CI, 1.3-1.5) and male recipient sex (HR, 1.5; 95% CI, 1.0-2.2). Recipient age was inversely associated with initiation of CAV (HR, 0.8; 95% CI, 0.8-1.0). Analysis of the interaction between donor and recipient age was not significant for death (p = 0.8) or CAV (p = 0.6). CONCLUSIONS: We found no interaction between donor and recipient age negatively affecting mortality and CAV. The identified independent risk factors may have implications for allocation strategies in elderly recipients.

Two-dimensional speckle tracking echocardiography in heart transplant patients: three-year follow-up of deformation parameters and ejection fraction derived from transthoracic echocardiography.

AIMS: Non-invasive diagnosis of allograft dysfunction is a major objective in the management of heart transplant (HTX) recipients. Speckle tracking echocardiography (STE) permits comprehensive assessment of myocardial function. It is well established that deformation indices are reduced in HTXs when compared with control subjects. However, it is unclear if the reduction in strain is a chronic progressive phenomenon in HTX patients. Method and results Follow-up transthoracic echocardiography (TTE) was performed 3 years after initial TTE in 20 'healthy' HTX patients (13.2 years post-transplantation at time of follow-up) with normal ejection fraction and angiographically ruled out allograft vasculopathy. Grey-scale apical views were recorded and stored for automated offline speckle tracking (EchoPAC 7.0, GE) of the 16 segments of the left ventricle. Strain analysis was performed in 320 segments 34.3 ± 3.7 months after initial assessment. Automated tracking of myocardial deformation for determination of longitudinal systolic strain was not possible in 24 (7.5%) segments at baseline and in 32 (10.0%) segments at follow-up (P = ns). The left ventricular ejection fraction (LVEF) was 61.9 ± 8.1% at the initial examination vs. 62.8 ± 5.8% 3 years afterwards (P = ns). Global longitudinal peak systolic strain was -14.0 ± 4.0 vs. -14.4 ± 2.8%, respectively (P = ns). CONCLUSION: This is the first study describing follow-up deformation parameters in HTX patients undergoing STE. 'Healthy' HTX patients with normal coronary arteries and normal ejection fractions showed no deterioration of longitudinal strain values 3 years after the initial assessment. Apparently, deformation values remain stable over the years as long as the LVEF is preserved.

Donor myocardial apollon mRNA is associated with cardiac allograft rejection.

BACKGROUND: Endomyocardial biopsy (EMB) is the "gold standard" in cardiac allograft acute cellular rejection (ACR) diagnosis, but it is invasive. ACR prediction at organ harvest could reduce EMB frequency in low-risk recipients. ACR is reportedly associated with apoptosis and Apollon inhibits apoptosis and promotes cell survival. It is unknown whether donor myocardial tissue Apollon mRNA could predict ACR. METHODS: Left ventricular biopsies (LVBs) were obtained from 336 donors before and after aortic cross-clamping (ACC) and at 10, 30 and 60 minutes of reperfusion in recipients. Tissue Apollon messenger RNA (mRNA) expression was examined by real-time reverse transcript-polymerase chain reaction (RT-PCR) and correlated with ACR episodes. RESULTS: Apollon LVB expression was significantly decreased before and after ACC in donors and at 10 minutes of reperfusion (p < or = 0.0233) in recipients who developed Grade 2R and 3R ACR as compared with those with Grade 1R or no ACR. In addition, Apollon myocardial expression was significantly decreased at 10 minutes of reperfusion in patients who developed Grade 3R ACR compared with all other ACR grades (p < or = 0.0425). In receiver-operating characteristic curve analysis, at a cut-off level of 75.66 arbitrary units, Apollon mRNA before ACC in donors identified combined Grade 2R and 3R ACR with a sensitivity of 94% and a specificity of 96% (p < 0.0001; area under the curve [AUC] = 0.965; odds ratio [OR] = 0.958; 95% confidence interval [CI] 0.942 to 0.974). CONCLUSIONS: Apollon is a sensitive and specific predictor of ACR in donated cardiac allografts and may have important implications in the choice of surveillance.

[Evaluation of the potential organ donor with special regards to heart donation]. / Der potentielle Organspender - Evaluierung unter besonderer Berücksichtigung der Herzentnahme.

Regarding limited availability of organ donors for heart transplantation, it is necessary to discuss optimal donor evaluation and donor management. In this manuscript general donor-related parameters as well as heart-specific parameters are discussed regarding international literature. In addition, "marginal" donors and in contrast "optimal" donors are defined. Donor management including optimal hemodynamic management and additional specific intensive care aspects are presented. Exact donor evaluation allows for matching the organ to the most suitable recipient and is therefore especially in the context of marginal donors a crucial step within transplantation process.

Calcineurin-inhibitor minimization protocols in heart transplantation.

Cardiac transplantation has become an established method for end-stage heart disease. A calcineurin-inhibitor (CNI)-based regimen is the cornerstone of immunosuppressive therapy after cardiac transplantation. CNIs have reduced acute rejection and infection and markedly increased survival of cardiac transplantation patients. However, the dose- and time-dependent nephrotoxic effects of CNIs can limit long-term survival, and chronic renal failure is a major cause of morbidity and mortality in long-term cardiac transplant patients. Early experience on withdrawal of CNIs (and maintenance of patients on azathioprine and steroids) in patients, who developed chronic renal dysfunction, resulted in rejection episodes with, sometimes, fatal outcome. The introduction of newer immunosuppressive drugs, like thymoglobulin, anti CD-25 monoclonal antibodies, mycophenolate mofetil, everolimus or sirolimus into clinical practice, has given transplant physicians new tools to adapt immunosuppression to patients' needs. Changes of immunosuppressive protocols by using new drugs early and late after transplantation and simultaneous reduction or weaning of CNIs have become attractive options. The aim of this article is to review strategies to delay, reduce or prevent CNIs after cardiac transplantation as means to improve short- and long-term outcome mainly by protecting renal function.

Safety and efficacy of statin therapy in patients switched from cyclosporine a to sirolimus after cardiac transplantation.

INTRODUCTION: Statins are an established therapy after cardiac transplantation. Sirolimus (Srl) has been used successfully in cardiac transplant patients. However, potential side effects are hyperlipidemia and interactions with statins. The aim of the study was to evaluate the safety and efficacy of statin therapy after switch to a Srl-based immunosuppression. PATIENTS AND METHODS: Ninety-eight long-term patients were switched from Cyclosporine A to Srl. Also all patients received mycophenolate mofetil alone or mycophenolate mofetil plus steroid therapy. Reasons for switch were renal dysfunction, graftvasculopathy, or skin cancer. Patients were switched 7.8+/-4.7 years after transplant. Total observation period was 12 months before and after switch, respectively. Safety evaluation consisted of regular measurements of CPK and liver enzymes to evaluate the incidence myopathy and hepatoxicity. Efficacy analysis was performed by serial blood lipid assessments (low-density lipoprotein, high-density lipoprotein, total cholesterol, and triglycerides). RESULTS: Forty-three percentage of patients received atorvastatin, 38% pravastatin, and 18% other drugs or therapy changes. Most lipid blood levels increased significantly after switch (cholesterol: 192.9+/-38.6 mg/dL vs. 221.8+/-49.2 mg/dL, P<0.0001; low-density lipoprotein: 108.0+/-35.6 mg/dL vs. 123.8+/-37.9 mg/dL, P<0.0001; and triglycerides: 178.3+/-88.2 mg/dL vs. 225.5+/-139.1 mg/dL, P<0.0001). Blood lipid levels after switch were not associated with statin type. Overall safety was acceptable, although incidence of myopathy doubled after switch (n=20 vs. 40; P<0.01). However, most cases were asymptomatic CPK elevations in the pravastatin group. Hepatotoxicity rate was 4% and only temporary. CONCLUSION: Statin therapy after switch from cyclosporine A to Srl in long-term cardiac transplant patients is safe. However, regular testing of blood lipids and CPK should be mandatory.

Detection of high-grade stenoses with multislice computed tomography in heart transplant patients.

BACKGROUND: Post-transplant follow-up of heart transplant patients consists of repeated coronary angiography, which is associated with high costs, discomfort and risk. We sought to determine whether multislice computed tomography (MSCT) permits the exclusion or progression of coronary artery disease in heart transplant patients. METHODS: MSCT scanning (Philips CT MX 8000 IDT) and invasive coronary angiography were performed on 66 consecutive heart transplant patients. One hundred milliliters of non-ionic iodinated contrast medium was applied for CT angiography. For MSCT analysis, coronary arteries and side branches with a diameter > or =1.5 mm were assessed for the presence of luminal narrowing of >70%. MSCT results were compared with those of quantitative coronary angiography analysis. RESULTS: Ten patients (17%) had one significant stenosis, whereas 3 patients (5%) had 2-vessel disease and none had 3-vessel disease. MSCT was performed successfully on 60 patients enrolled in our analysis. Forty-two of 44 patients (95%) who were estimated to be fully evaluable for MSCT were correctly classified. On per-segment-based analysis, sensitivity, specificity and positive and negative predictive values were 59%, 94%, 91% and 99.43%, respectively. After exclusion of unevaluable segments, sensitivity and specificity increased to 71% and 99.86%, respectively. On per-patient-based analysis, sensitivity, specificity and positive and negative predictive values were 88%, 97%, 88% and 97%, respectively, in evaluable transplant recipients. CONCLUSIONS: MSCT with its high specificity and high negative predictive value allows the exclusion of significant coronary artery vasculopathy in evaluable patients. From the clinical point of view, this might spare additional invasive coronary angiography in heart transplant patients.

Recent trends in heart transplantation: the University of Vienna experience.

Since the beginning of the University of Vienna Cardiac Transplant Program in 1984, 1086 heart transplant procedures have been performed through the end of 2007. One- and five-year survival has increased steadily over time (82% and 76%). Ten-year survival is 65%. Over the past 10 years our program has seen dramatic changes in patient selection, accepting now patients with more risk factors (Age, diabetes, elevated pulmonary resistance,..). Developments in immunosuppression have decreased incidence of infection, rejection and graft arteriosclerosis continuously. Our program continues to pursue novel strategies to improve the survival and quality of life of our heart transplant patients.