Doppler echocardiography for surveillance of acute cardiac allograft rejection: a 28-year single-center experience.

Background: Endomyocardial biopsies (EMB) are recommended for the detection of acute cardiac rejection (ACR) despite limited sensitivity. We report the long-term post-transplant results of Doppler echocardiography as a noninvasive alternative of routine EMB. Methods: Two cohorts of heart transplantation (HT) recipients were chronologically defined as follows: the Dual Monitoring Cohort (DMC) from January 1990 to December 1997 included patients who underwent routine EMB and Doppler echocardiography within 24 hours for ACR surveillance; and the "Echo-First Cohort" (EFC), including patients transplanted from January 1998 to December 2018 with Doppler echocardiography as first-line approach for ACR surveillance. Echocardiographic measurements of interest were collected: early diastolic (E) wave peak velocity; pressure half time (PHT) and isovolumetric relaxation time (IVRT). Post-transplant outcomes were reviewed and the Kaplan-Meier approach was used for survival estimates. Inter-operator variability for ultrasound measurements was investigated. Data were collected from medical records from January 2019 to December 2020. Results: A total of 228 patients were included, 99 patients in the DMC and 129 in the EFC. Overall, 5-, 10- and 15-year survival rates were 65.4%, 55.5% and 44.1% respectively, without any significant difference between the two cohorts (log rank test, P=0.71). Echocardiography variables and EMB findings were associated with a mean area under the receiver operating characteristic curve (AUC-ROC) of 0.73 [95% confidence interval (CI): 0.54-0.91], 0.74 (95% CI: 0.54-0.94) and 0.75 (95% CI: 0.57-0.94) respectively for E wave, PHT and IVRT. IVRT and PHT were significantly decreased, and E wave significantly increased, in case of histologically proven ACR. Inter-operator variability was not significant for E wave and IVRT measurements (P=0.13 and 0.30 respectively). Conclusions: Doppler echocardiography as a first-line method for surveillance of ACR did not impair long-term results after HT. These findings suggest that this non-invasive approach might be a reasonable alternative to systematic EMB, limiting risk and improving the quality of life.

Urgent desensitization in patients bridged to heart transplantation under extracorporeal membrane oxygenation support: A preliminary experience.

Antihuman leukocyte antigen (HLA) antibodies restrict the access to cardiac allografts. Desensitization therapy is a major challenge in patients with cardiogenic shock waiting for urgent heart transplantation (HT). We retrospectively reviewed six patients (mean age of 37.5 years [16-70]) who underwent plasmapheresis (PP) under extracorporeal membrane oxygenation (ECMO) before transplant between January 2017 and September 2018. The average duration of follow-up was 25 months [20-32]. Mean fluorescence intensity (MFI) of HLA-specific antibodies was reported as follows: score 4 for MFI < 1000, score 6 for 1000 < MFI < 3000 and score 8 for MFI > 3000. The mean duration of ECMO support was 29 days [1-74] and 6.8 [1-29] PP sessions were performed per patient before transplant. The mean number of HLA-specific antibodies before HT was 9.6 for score 6 [4-13] and 5.8 for score 8 [1-12]. Four patients had major complications after transplantation (2 hemorrhagic shocks, 5 infectious events). Mean MFI reduction rate was 94% [79-100] for Class I and 44.2% for Class II [0-83]. Hospital survival was 100%, and early antibody-mediated rejection was diagnosed in one patient at 7 days after HT. Plasmapheresis under ECMO support was associated with favorable early outcomes in highly sensitized candidates for urgent heart transplantation.

Early and mid-term cardiovascular outcomes following TAVI: impact of pre-procedural transvalvular gradient.

OBJECTIVE: To assess the relation of aortic transvalvular gradient with outcomes following transcatheter aortic valve implantation (TAVI). BACKGROUND: Relatively little is known about the predictors of adverse outcomes in patients with severe aortic stenosis following TAVI. METHODS: We studied 126 consecutive patients (mean age 83.2 ± 6.3 years; 59% women) who underwent TAVI (23% transapical; 77% transfemoral) at our institution. All patients were followed for the incidence of major adverse cardiovascular events (MACE), including myocardial infarction, heart failure, stroke, and cardiovascular death. RESULTS: The acute procedural success rate was 98%; at 1 year, the cumulative incidence of MACE and cardiovascular death was 29% and 10%, respectively. In multivariable analyses adjusting for clinical and echocardiographic risk factors, presence of a baseline mean transvalvular gradient (MTG) <40 mmHg was a significant predictor of 30-day MACE in the total sample (OR 4.4, 95% CI 1.7-11.4; P=0.003) as well as in patients with an ejection fraction ≥ 50% (OR 10.3, 95% CI 3.0-33.4; P<0.001). In multivariable analyses, low MTG was also associated with 2-fold and 4-fold increased hazards for MACE (HR 4.2, 95% CI 2.0-8.9; P<0.001) and cardiovascular death (HR 4.2 95% CI 1.2-14.9; P=0.03), respectively, within 1 year following TAVI. CONCLUSION: Presence of a low MTG (<40 mmHg) prior to TAVI was associated with a greater risk of major adverse events, including cardiovascular death, up to 1 year following the procedure. Pre-procedural MTG could be used to identify patients at a high risk for adverse outcomes following TAVI.

Incidence, predictors and prognostic value of serious hemorrhagic complications following transcatheter aortic valve implantation.

BACKGROUND: TAVI is an alternative solution for patients with aortic valve stenosis (AS) who are refused for conventional surgery. We sought to evaluate the incidence, characteristics, predictors and prognosis impact of serious hemorrhagic complications following transcatheter aortic valve implantation (TAVI). METHODS: One hundred and seventy one consecutive patients with symptomatic severe AS (83.5 ± 6.1 y; 53% women; mean EuroSCORE=22.1 ± 12.3) underwent transapical (TA) or transfemoral (TF) TAVI in our institution using Edwards SAPIEN© and Medtronic CoreValve© devices. The primary evaluated criterion was the incidence of any bleeding complication, according to the Valve Academic Research Consortium (VARC) criteria. RESULTS: VARC serious hemorrhagic complications occurred in 34.5% of patients (n=23 life-threatening/disabling (LT/D) and n=36 major bleedings). Most of these complications were related to access site complications (69%). Multivariable analysis revealed that TA access, low weight and underlying coronary artery diseases were independent predictors for development of serious bleeding. The mortality was significantly higher in patients with serious events compared to patients without bleeding (p=0.008, log-rank analysis). Although the survival didn't significantly differ in patients with major hemorrhagic events, subjects with LT/D bleeding events had a higher mortality than the subjects with no hemorrhagic complications (p<0.001, log-rank analysis). Occurrence of VARC LT/D event independently predicted all-cause mortality (HR=5.35 [2.51-11.43], p<0.001) during the first year following TAVI in multivariate Cox regression analysis. CONCLUSION: Severe bleeding is frequent following TAVI procedure and is mainly related to local hemorrhage. VARC LT/D events are associated with decreased survival after AS correction.

Heart transplant patient outcomes: 5-year mean follow-up by coronary computed tomography angiography.

BACKGROUNDS: We evaluate the feasibility and safety of coronary computed tomography angiography (CCTA) as the first-line investigation in heart transplant patients and the rate of coronary allograft vasculopathy detected using CCTA. METHODS: From September 2003 to June 2009, we prospectively included 65 heart transplant recipients, retaining 62 who underwent yearly CCTA for coronary allograft vasculopathy detection (261 CCTAs). We used 16-slice, 64-slice, and 2×64-slice CT machines. Patients with coronary artery stenosis by CCTA had a confirmation and a further follow-up exclusively by conventional coronary angiography (CCA). RESULTS: No major coronary events occurred during the study. Of the 62 baseline CCTAs, 37 (60%) were normal, 18 (29%) showed wall thickening, and 7 (11%) known significant stenosis, confirmed by CCA. The mean follow-up duration was 5 years. At the last follow-up, 26 (70%) patients with normal baseline findings remained normal, 9 (24%) had wall thickening, and 2 (6%) significant stenoses. Time to stenosis was consistently greater than 3 years. Of the 18 patients with initially wall thickening, 14 (78%) had wall thickening and 4 (22%) significant stenosis at last follow-up. The mean interval without any coronary lesion was 9.46±3.98 years. The mean interval without de novo significant stenosis was 10.31±4 years. CONCLUSIONS: CCTA seems to be a safe noninvasive tool for monitoring heart transplant patients, and thus obviating the need for CCA. In patients with normal baseline CCTA, a 2-year interval between CCTAs may be safe.