病毒性心肌内膜感染是小儿心脏移植受者移植物丢失和冠状动脉血管病的独立预测因子和潜在可治疗的危险因素。
Viral endomyocardial infection is an independent predictor and potentially treatable risk factor for graft loss and coronary vasculopathy in pediatric cardiac transplant recipients.
机构信息
Department of Pediatrics (Cardiology), University of Texas Health Sciences Center, Houston, TX, USA.
出版信息
J Am Coll Cardiol. 2010 Aug 10;56(7):582-92. doi: 10.1016/j.jacc.2010.02.060.
OBJECTIVES
This study sought to evaluate the outcome and prevalence of viral endomyocardial infection after cardiac transplantation.
BACKGROUND
Viral myocardial infection causes heart failure, but its role after cardiac transplantation is unclear. We hypothesized that viral infection of the cardiac allograft reduces graft survival.
METHODS
Between June 1999 and November 2004, 94 pediatric cardiac transplant patients were screened for the presence of viral genome in serial endomyocardial biopsies (EMBs) using polymerase chain reaction (PCR) assays. Graft loss, advanced transplant coronary artery disease (TCAD), and acute rejection (AR) were compared in the PCR-positive (n = 37) and PCR-negative (n = 57) groups, using time-dependent Kaplan-Meier and Cox regression analyses. From November 2002 to November 2004, intravenous immunoglobulin therapy (IVIG) was administered to patients with PCR-positive EMBs. The outcomes of the IVIG-treated, PCR-positive patients (n = 20) were compared with IVIG-untreated, PCR-positive patients (n = 17).
RESULTS
Viral genomes were detected in EMBs from 37 (39%) patients; parvovirus B19, adenovirus, and Epstein-Barr virus (EBV) were the most common. The PCR-positive group (n = 37, 25% graft loss at 2.4 years) had decreased graft survival (p < 0.001) compared with the PCR-negative group (n = 57, 25% graft loss at 8.7 years) and developed advanced TCAD prematurely (p = 0.001). The number of AR episodes was similar in both groups. On multivariate analysis, presence of viral genome was an independent risk factor for graft loss (relative risk: 4.2, p = 0.015). The time to advanced TCAD after becoming PCR-positive was longer in the IVIG-treated patients (p = 0.03) with a trend toward improved graft survival (p = 0.06).
CONCLUSIONS
Viral endomyocardial infection is an independent predictor of graft loss in pediatric cardiac transplant recipients. This effect appears to be mediated through premature development of advanced TCAD. IVIG therapy in this subgroup may improve survival and merits further investigation.
目的
本研究旨在评估心脏移植后病毒性心内膜炎的转归和流行情况。
背景
病毒性心肌感染可导致心力衰竭，但在心脏移植后的作用尚不清楚。我们假设心脏移植物的病毒感染会降低移植物的存活率。
方法
1999 年 6 月至 2004 年 11 月期间，通过聚合酶链反应（PCR）检测 94 例儿科心脏移植患者连续心内膜心肌活检（EMB）中的病毒基因组，评估病毒存在情况。使用时间依赖性 Kaplan-Meier 和 Cox 回归分析比较 PCR 阳性（n = 37）和 PCR 阴性（n = 57）组之间的移植物丢失、晚期移植性冠状动脉疾病（TCAD）和急性排斥反应（AR）。从 2002 年 11 月至 2004 年 11 月，对 PCR 阳性的 EMB 患者给予静脉注射免疫球蛋白治疗（IVIG）。比较 IVIG 治疗的 PCR 阳性患者（n = 20）和 IVIG 未治疗的 PCR 阳性患者（n = 17）的结局。
结果
37 例（39%）患者的 EMB 中检测到病毒基因组；微小病毒 B19、腺病毒和 Epstein-Barr 病毒（EBV）最为常见。PCR 阳性组（n = 37，2.4 年时 25%移植物丢失）的移植物存活率降低（p < 0.001），明显低于 PCR 阴性组（n = 57，8.7 年时 25%移植物丢失），并且早期出现晚期 TCAD（p = 0.001）。两组 AR 发作次数相似。多变量分析显示，病毒基因组的存在是移植物丢失的独立危险因素（相对风险：4.2，p = 0.015）。在成为 PCR 阳性后发生晚期 TCAD 的时间，IVIG 治疗组患者较长（p = 0.03），且移植物存活率有改善趋势（p = 0.06）。
结论
病毒性心内膜炎是儿科心脏移植受者移植物丢失的独立预测因子。这种作用似乎是通过早期发生晚期 TCAD 介导的。该亚组患者的 IVIG 治疗可能改善存活率，值得进一步研究。
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