Pamboukian Salpy V, Costanzo Maria Rosa, Dunlap Stephanie, Rayburn Barry, Westfall Andrew O, You Z Y, Hung Elena, McLeod Mary, Heroux Alain
University of Alabama at Birmingham, Birmingham, AL 35242, USA.
J Heart Lung Transplant. 2005 Mar;24(3):310-5. doi: 10.1016/j.healun.2003.12.008.
Ventricular assist devices (VADs) are commonly used to bridge patients to heart transplantation. Recipients of VADs may develop anti-human histocompatibility leukocyte antigen antibodies, as reflected by elevated panel-reactive antibodies (PRA). The purpose of this study was to evaluate the relationship between bridging with VAD before heart transplantation and development of cellular rejection, humoral rejection, and allograft vasculopathy after transplantation.
Data on all patients who underwent cardiac transplantation between July 1994 and February 2001 at Rush Presbyterian St Luke's Medical Center were retrospectively reviewed. Data collected included sex, age, etiology of cardiomyopathy, percentage panel reactive antibodies (by cytotoxic method), type and duration of mechanical circulatory support, transfusion history, rejection history (both cellular and humoral) after cardiac transplantation, and development of allograft vasculopathy. Cellular rejection was treated when International Society of Heart and Lung and Transplantation Grade 2 or greater in the first 12 months after transplant and Grade 3 or greater after 12 months and treated with intensification of immunosuppression. Humoral rejection was defined clinically as allograft dysfunction by echocardiography without evidence of cellular rejection on endomyocardial biopsy or allograft vasculopathy. Allograft vasculopathy was defined by presence of any degree of luminal narrowing or pruning of distal vessels by coronary arteriography. Statistical analyses were performed by chi-square test, Fisher's exact test, and Wilcoxon rank sum test, as appropriate.
Ninety-eight patients underwent cardiac transplantation during the study period (87 men, mean age 49 years, 46 ischemic etiology). Of these, 48 were bridged with HeartMate VAD (20 patients received vented electric device, 28 received pneumatic device). Nineteen percent of VAD patients had a peak pretransplant PRA > or =10% vs 2% of patients without VAD (p = 0.014). PRA > or =10%, use of VAD, or duration of VAD support did not predict development of humoral rejection. Use of VAD did not predict development of cellular rejection or allograft vasculopathy. VAD use was not associated with sudden death after heart transplantation. In the entire group of 98 patients, neither humoral nor cellular rejection predicted development of allograft vasculopathy. Longer ischemic time correlated with increased cellular rejection and humoral rejection after transplantation (p = 0.01).
Some patients bridged to cardiac transplantation with VADs have increased PRA before heart transplantation, but this does not appear to translate into increased risk of either humoral or cellular rejection after transplantation or development of allograft vasculopathy as detected by coronary angiography.
心室辅助装置（VADs）常用于将患者过渡到心脏移植。VADs接受者可能会产生抗人类组织相容性白细胞抗原抗体，这可通过群体反应性抗体（PRA）升高来反映。本研究的目的是评估心脏移植前使用VAD过渡与移植后细胞排斥、体液排斥及移植血管病发生之间的关系。
回顾性分析1994年7月至2001年2月在拉什长老会圣卢克医疗中心接受心脏移植的所有患者的数据。收集的数据包括性别、年龄、心肌病病因、群体反应性抗体百分比（通过细胞毒性法）、机械循环支持的类型和持续时间、输血史、心脏移植后的排斥史（细胞和体液排斥）以及移植血管病的发生情况。移植后前12个月国际心肺移植学会分级为2级或更高、12个月后为3级或更高时治疗细胞排斥，并加强免疫抑制治疗。体液排斥临床上定义为经超声心动图显示移植器官功能障碍，而心内膜活检或移植血管病未发现细胞排斥证据。移植血管病通过冠状动脉造影显示远端血管存在任何程度的管腔狭窄或分支减少来定义。根据情况进行卡方检验、Fisher精确检验和Wilcoxon秩和检验。
在研究期间，98例患者接受了心脏移植（87例男性，平均年龄49岁，46例为缺血性病因）。其中，48例使用HeartMate VAD过渡（其中20例接受带孔电动装置，28例接受气动装置）。19%的VAD患者移植前PRA峰值≥10%，而未使用VAD的患者为2%（p = 0.014）。PRA≥10%、使用VAD或VAD支持时间并不能预测体液排斥的发生。使用VAD不能预测细胞排斥或移植血管病的发生。使用VAD与心脏移植后猝死无关。在这98例患者的整个队列中，体液排斥和细胞排斥均不能预测移植血管病的发生。较长的缺血时间与移植后细胞排斥和体液排斥增加相关（p = 0.01）。
一些使用VAD过渡到心脏移植的心衰患者在心脏移植前PRA升高，但这似乎并未转化为移植后体液或细胞排斥风险增加，也未转化为冠状动脉造影检测到的移植血管病风险增加。
