Heart Transplantation for Giant Cell Myocarditis: A Case Series

BackgroundGiant cell myocarditis (GCM) has a poor prognosis without heart transplant, but post-transplant survival is unknown.PurposeTo describe the post-transplant survival of patients with GCM at a large transplant center.MethodsSeven patients underwent heart transplant for histologically confirmed GCM of the explanted heart. The median age was 59 years, and 43% (3 of 7) were female. All patients had cardiogenic shock, multiorgan failure, elevated troponin, and recurrent ventricular tachycardia, and some required mechanical circulatory support. All patients received rabbit antithymocyte globulin (rATG) in the perioperative period at a dose of 1.5 mg/kg daily for 1 to 5 days and 4 received intravenous immunoglobulin 1 g/kg daily for 2 days after rATG. All patients had early initiation of tacrolimus by first to third postoperative day depending on renal function, early mycophenolate, and high dose steroid. All were maintained using tacrolimus, mycophenolate, and prednisone.ResultsOne patient had asymptomatic recurrence of GCM at 3 months, managed by up-titration of tacrolimus, and had asymptomatic 2R cellular rejection at 4 months, managed with steroid bolus. No patient had high-grade rejection. One patient died at 267 days, possibly of GCM. Six of 7 (86%) remain alive at a median of 842 days (2.3 years) post transplant.ConclusionsPatients with GCM have excellent post-transplant survival with use of rATG and triple drug immunosuppressive therapy; however, some patients remain at risk for GCM recurrence after transplant, which may respond to augmented immunosuppression.     

Complement inhibition for prevention of antibody-mediated rejection in immunologically high-risk heart allograft recipients

Allosensitization represents a major barrier to heart transplantation (HTx). We assessed the efficacy and safety of complement inhibition at transplant in highly sensitized heart transplant recipients. We performed a single-center, single-arm, open-label trial (NCT02013037). Patients with panel reactive antibodies (PRA) ≥70% and pre–formed donor-specific antibodies (DSA) were eligible. In addition to standard of care, patients received nine infusions of eculizumab during the first 2 months posttransplant. The primary composite endpoint was antibody-mediated rejection (AMR) ≥pAMR2 and/or left ventricular dysfunction during the first year. Secondary endpoints included hemodynamic compromise, allograft rejection, and patient survival. Twenty patients were included. Median cPRA and mean fluorescence intensity of immunodominant DSA were 95% (90%–97%) and 6250 (5000–10 000), respectively. Retrospective B cell and T cell flow crossmatches were positive in 14 and 11 patients, respectively. The primary endpoint occurred in four patients (20%). Survival at 1 year was 90% with no deaths resulting from AMR. In a prespecified analysis comparing treated patients to matched control patients, we observed a dramatic reduction in the risk of biopsy-proven AMR in patients treated with eculizumab (HR = 0.36, 95% CI = 0.14–0.95, p = .032). Our findings support the prophylactic use of complement inhibition for heart transplantation at high immunological risk. ClinincalTrials.gov, NCT02013037.     

Coronary computed tomography–angiography quantitative plaque analysis improves detection of early cardiac allograft vasculopathy: A pilot study

Cardiac allograft vasculopathy (CAV) is an increasingly important complication after cardiac transplant. We assessed the additive diagnostic benefit of quantitative plaque analysis in patients undergoing coronary computed tomography–angiography (CCTA). Consecutive patients undergoing CCTA for CAV surveillance were identified. Scans were visually interpreted for coronary stenosis. Semiautomated software was used to quantify noncalcified plaque (NCP), as well as its components. Optimal diagnostic cut‐offs for CAV, with coronary angiography as gold standard, were defined using receiver operating characteristic curves. In total, 36 scans were identified in 17 patients. CAV was present in 17 (46.0%) reference coronary angiograms, at a median of 1.9 years before CCTA. Median NCP (147 vs 58, P < .001), low‐density NCP (median 4.5 vs 0.9, P = .003), fibrous plaque (median 76.1 vs 31.1, P = .003), and fibrofatty plaque (median 63.6 vs 27.6, P < .001) volumes were higher in patients with CAV, whereas calcified plaque was not (median 0.0 vs 0.0, P = .510). Visual assessment of CCTA alone was 70.6% sensitive and 100% specific for CAV. The addition of total NCP volume increased sensitivity to 82.4% while maintaining 100% specificity. NCP volume is significantly higher in patients with CAV. The addition of quantitative analysis to visual interpretation improves the sensitivity for detecting CAV without reducing specificity.     

Does patent foramen ovale promote cryptogenic stroke and migraine headache?

Cryptogenic stroke is a diagnosis of exclusion. These are strokes that occur in people who are usually less than 55 years old, without an identifiable cause. Our sensitivity to these events has been heightened because of the new definitions of a transient ischemic attack. Transient ischemic attack (TIA) is a clinical diagnosis of a neurologic deficit without MRI abnormalities: if there is an MRI abnormality, whether or not that person is symptomatic, it is now defined as a stroke. With these new definitions, and the sensitivity of MRI, we are seeing more cryptogenic strokes. It has been hypothesized that many cryptogenic strokes are caused by small emboli that travel from the legs to the right atrium; during straining (such as a Valsalva maneuver) these emboli can go across a PFO into the left atrium and then travel to the brain, producing a stroke. The problem is that these are very small emboli, approximately 1 to 3 mm, and we can't actually show these small emboli crossing from right to left. However, large emboli have been observed by echocardiography to be trapped in the PFO. So the diagnosis of cryptogenic stroke is a diagnosis of exclusion that is impossible to verify. What is the scope of the problem? Of the 700,000 strokes per year in the United States, 80% of them are ischemic, and 20% of those are defined as cryptogenic. The prevalence of PFO among this cryptogenic stroke population is about 40% to 50%; in the general population, it's only about 20%. Current estimates are that somewhere between 30,000 and 60,000 strokes per year in the U.S. are caused by paradoxical embolism through a PFO. There are some other fascinating associations: scuba divers with PFOs are more susceptible to decompression illness. Platypnea-orthodeoxia is a condition of desaturation that occurs when you're standing up but not when you're lying down; these patients are quite symptomatic, with arterial saturations in the low 80s. They also frequently have PFOs; if you close the PFO, the arterial desaturation is alleviated. Fat emboli during orthopedic surgery or air emboli during neurosurgery may also travel through the venous system. If you don't have a PFO, the fat or the air is trapped in the lungs and doesn't cause much of a problem unless it's massive; but if you have a PFO, then the embolus can go from right to left atrium up to the brain, with devastating neurologic consequences.     

Results of routine shunting and patch closure during carotid endarterectomy

BackgroundThe role of shunting and patching during carotid endarterectomy remains controversial.MethodsThis is a retrospective case series evaluating consecutive patients undergoing carotid endarterectomy with routine shunting and patching. The primary endpoints were perioperative stroke, arterial injury, and lesion recurrence by duplex.ResultsOf the 220 operations performed, 43% were for symptomatic disease. Successful shunt placement occurred in 98%, with no shunt-related injuries. There was 1 minor perioperative stroke and no major strokes. At a mean follow-up of 24 months (median = 12 months), there was 1 restenosis potentially related to shunt placement. The incidence of asymptomatic >50% stenosis in the patched segment was 8%.ConclusionsA combined policy of routine shunting and patching simplifies intraoperative decision making with results that rival or exceed those of trials in which their use was not standardized. Shunts need not be avoided because of concern of arterial injury.     

Predictive value of neutrophil-to-lymphocyte ratio in diabetic wound healing

Objective

The neutrophil-to-lymphocyte ratio (NLR) has been used as a surrogate marker of systemic inflammation. We sought to investigate the association between NLR and wound healing in diabetic wounds.