Transplantation of high panel-reactive antibody left ventricular assist device patients without crossmatch using on-bypass pheresis and alemtuzumab

Scott D. Lick, Daniel L. Beckles, Giovanni Piovesana, Smita Vaidya, Alexander Indrikovs, N. Alexander Barbagelata, Vincent Valentine

Research output: Contribution to journalArticle

8 Citations (Scopus)

Abstract

Background: Highly sensitized (HS) left ventricular assist device (LVAD) patients with high panel-reactive antibody (PRA) levels present a challenge. Alemtuzumab, a potent depleting agent for T and B lymphocytes (months to years), and plasmapheresis, offer an opportunity for heart transplantation to these patients who might die of VAD complications on the transplant waiting list. This study compared rates of acute rejection and survival of a HS LVAD cohort with a contemporaneous control group after heart transplant. Methods: Clinical courses of 31 consecutive patients who underwent transplantation between January 2006 and January 2011 were reviewed. Eight patients with a T or B PRA of 70 or more (HS+) received non-crossmatched, ABO-compatible hearts using intraoperative plasmapheresis and alemtuzumab induction. Controls (HS) received basiliximab induction. Acute rejection was defined as International Society for Heart and Lung Transplantation grades 2R or higher, or antibody-mediated rejection. Results: The difference in survival between HS+ and HS groups at 1 year (100% vs 94%) or at a mean follow-up of 2.3 and 2.4 years (75% vs 70%) was not significant. Retrospective lymphocytotoxic crossmatches were positive in 7 of 8 HS+ patients (6 T+ and B+, 1 B+) vs none in the HS group (p < 0.001). There was a trend toward increased risk of cellular rejection per 100 patient-days beyond 1 year in the HS+ group (p = 0.07). Risk of humoral rejection was significantly increased in the HS+ group (38% vs 4%; p = 0.04). Conclusions: Heart transplantation with plasmapheresis and alemtuzumab in HS LVAD patients, most with a positive crossmatch, does not compromise midterm survival. The expected higher rates of rejection, especially beyond the first postoperative year, demand adjustments in surveillance strategies and immunosuppressive management.

Original languageEnglish (US)
Pages (from-to)1428-1434
Number of pages7
JournalAnnals of Thoracic Surgery
Volume92
Issue number4
DOIs
StatePublished - Oct 2011

Fingerprint

Blood Component Removal
Heart-Assist Devices
Transplantation
Antibodies
Plasmapheresis
Heart Transplantation
Survival
Transplants
Waiting Lists
Immunosuppressive Agents
alemtuzumab
B-Lymphocytes
T-Lymphocytes
Control Groups

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery
  • Pulmonary and Respiratory Medicine

Cite this

Transplantation of high panel-reactive antibody left ventricular assist device patients without crossmatch using on-bypass pheresis and alemtuzumab. / Lick, Scott D.; Beckles, Daniel L.; Piovesana, Giovanni; Vaidya, Smita; Indrikovs, Alexander; Barbagelata, N. Alexander; Valentine, Vincent.

In: Annals of Thoracic Surgery, Vol. 92, No. 4, 10.2011, p. 1428-1434.

Research output: Contribution to journalArticle

Lick, Scott D. ; Beckles, Daniel L. ; Piovesana, Giovanni ; Vaidya, Smita ; Indrikovs, Alexander ; Barbagelata, N. Alexander ; Valentine, Vincent. / Transplantation of high panel-reactive antibody left ventricular assist device patients without crossmatch using on-bypass pheresis and alemtuzumab. In: Annals of Thoracic Surgery. 2011 ; Vol. 92, No. 4. pp. 1428-1434.
@article{b3ada90b9e0e44478031b2a9613aecf8,
title = "Transplantation of high panel-reactive antibody left ventricular assist device patients without crossmatch using on-bypass pheresis and alemtuzumab",
abstract = "Background: Highly sensitized (HS) left ventricular assist device (LVAD) patients with high panel-reactive antibody (PRA) levels present a challenge. Alemtuzumab, a potent depleting agent for T and B lymphocytes (months to years), and plasmapheresis, offer an opportunity for heart transplantation to these patients who might die of VAD complications on the transplant waiting list. This study compared rates of acute rejection and survival of a HS LVAD cohort with a contemporaneous control group after heart transplant. Methods: Clinical courses of 31 consecutive patients who underwent transplantation between January 2006 and January 2011 were reviewed. Eight patients with a T or B PRA of 70 or more (HS+) received non-crossmatched, ABO-compatible hearts using intraoperative plasmapheresis and alemtuzumab induction. Controls (HS) received basiliximab induction. Acute rejection was defined as International Society for Heart and Lung Transplantation grades 2R or higher, or antibody-mediated rejection. Results: The difference in survival between HS+ and HS groups at 1 year (100{\%} vs 94{\%}) or at a mean follow-up of 2.3 and 2.4 years (75{\%} vs 70{\%}) was not significant. Retrospective lymphocytotoxic crossmatches were positive in 7 of 8 HS+ patients (6 T+ and B+, 1 B+) vs none in the HS group (p < 0.001). There was a trend toward increased risk of cellular rejection per 100 patient-days beyond 1 year in the HS+ group (p = 0.07). Risk of humoral rejection was significantly increased in the HS+ group (38{\%} vs 4{\%}; p = 0.04). Conclusions: Heart transplantation with plasmapheresis and alemtuzumab in HS LVAD patients, most with a positive crossmatch, does not compromise midterm survival. The expected higher rates of rejection, especially beyond the first postoperative year, demand adjustments in surveillance strategies and immunosuppressive management.",
author = "Lick, {Scott D.} and Beckles, {Daniel L.} and Giovanni Piovesana and Smita Vaidya and Alexander Indrikovs and Barbagelata, {N. Alexander} and Vincent Valentine",
year = "2011",
month = "10",
doi = "10.1016/j.athoracsur.2011.04.064",
language = "English (US)",
volume = "92",
pages = "1428--1434",
journal = "Annals of Thoracic Surgery",
issn = "0003-4975",
publisher = "Elsevier USA",
number = "4",

}

TY - JOUR

T1 - Transplantation of high panel-reactive antibody left ventricular assist device patients without crossmatch using on-bypass pheresis and alemtuzumab

AU - Lick, Scott D.

AU - Beckles, Daniel L.

AU - Piovesana, Giovanni

AU - Vaidya, Smita

AU - Indrikovs, Alexander

AU - Barbagelata, N. Alexander

AU - Valentine, Vincent

PY - 2011/10

Y1 - 2011/10

N2 - Background: Highly sensitized (HS) left ventricular assist device (LVAD) patients with high panel-reactive antibody (PRA) levels present a challenge. Alemtuzumab, a potent depleting agent for T and B lymphocytes (months to years), and plasmapheresis, offer an opportunity for heart transplantation to these patients who might die of VAD complications on the transplant waiting list. This study compared rates of acute rejection and survival of a HS LVAD cohort with a contemporaneous control group after heart transplant. Methods: Clinical courses of 31 consecutive patients who underwent transplantation between January 2006 and January 2011 were reviewed. Eight patients with a T or B PRA of 70 or more (HS+) received non-crossmatched, ABO-compatible hearts using intraoperative plasmapheresis and alemtuzumab induction. Controls (HS) received basiliximab induction. Acute rejection was defined as International Society for Heart and Lung Transplantation grades 2R or higher, or antibody-mediated rejection. Results: The difference in survival between HS+ and HS groups at 1 year (100% vs 94%) or at a mean follow-up of 2.3 and 2.4 years (75% vs 70%) was not significant. Retrospective lymphocytotoxic crossmatches were positive in 7 of 8 HS+ patients (6 T+ and B+, 1 B+) vs none in the HS group (p < 0.001). There was a trend toward increased risk of cellular rejection per 100 patient-days beyond 1 year in the HS+ group (p = 0.07). Risk of humoral rejection was significantly increased in the HS+ group (38% vs 4%; p = 0.04). Conclusions: Heart transplantation with plasmapheresis and alemtuzumab in HS LVAD patients, most with a positive crossmatch, does not compromise midterm survival. The expected higher rates of rejection, especially beyond the first postoperative year, demand adjustments in surveillance strategies and immunosuppressive management.

AB - Background: Highly sensitized (HS) left ventricular assist device (LVAD) patients with high panel-reactive antibody (PRA) levels present a challenge. Alemtuzumab, a potent depleting agent for T and B lymphocytes (months to years), and plasmapheresis, offer an opportunity for heart transplantation to these patients who might die of VAD complications on the transplant waiting list. This study compared rates of acute rejection and survival of a HS LVAD cohort with a contemporaneous control group after heart transplant. Methods: Clinical courses of 31 consecutive patients who underwent transplantation between January 2006 and January 2011 were reviewed. Eight patients with a T or B PRA of 70 or more (HS+) received non-crossmatched, ABO-compatible hearts using intraoperative plasmapheresis and alemtuzumab induction. Controls (HS) received basiliximab induction. Acute rejection was defined as International Society for Heart and Lung Transplantation grades 2R or higher, or antibody-mediated rejection. Results: The difference in survival between HS+ and HS groups at 1 year (100% vs 94%) or at a mean follow-up of 2.3 and 2.4 years (75% vs 70%) was not significant. Retrospective lymphocytotoxic crossmatches were positive in 7 of 8 HS+ patients (6 T+ and B+, 1 B+) vs none in the HS group (p < 0.001). There was a trend toward increased risk of cellular rejection per 100 patient-days beyond 1 year in the HS+ group (p = 0.07). Risk of humoral rejection was significantly increased in the HS+ group (38% vs 4%; p = 0.04). Conclusions: Heart transplantation with plasmapheresis and alemtuzumab in HS LVAD patients, most with a positive crossmatch, does not compromise midterm survival. The expected higher rates of rejection, especially beyond the first postoperative year, demand adjustments in surveillance strategies and immunosuppressive management.

UR - http://www.scopus.com/inward/record.url?scp=80053338023&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=80053338023&partnerID=8YFLogxK

U2 - 10.1016/j.athoracsur.2011.04.064

DO - 10.1016/j.athoracsur.2011.04.064

M3 - Article

C2 - 21855854

AN - SCOPUS:80053338023

VL - 92

SP - 1428

EP - 1434

JO - Annals of Thoracic Surgery

JF - Annals of Thoracic Surgery

SN - 0003-4975

IS - 4

ER -