Influence of durable mechanical circulatory support and allosensitization on mortality after heart transplantation

Abstract

Introduction Allosensitization has been shown to negatively impact post-heart transplant (HTx) survival even with a negative crossmatch. Whether MCS-related allosensitization is associated with worse post-HTx survival remains controversial. Materials and Methods Adult HTx recipients listed in the United Network for Organ Sharing database (7/06–12/12) were identified. Multivariate Cox regression assessed the effect of allosensitization on survival. Propensity matching was performed to compare allosensitized and non-sensitized patients. Kaplan-Meier survival analysis compared matched and unmatched patients in both the MCS and medically managed cohorts. Results We identified 11,840 HTx recipients, of whom 4,167 had MCS. MCS was associated with allosensitization in multivariate logistic regression. Each different MCS devices was associated with worse post-HTx survival in multivariate Cox regression. Allosensitization did not predict post-HTx mortality in MCS patients, HR: 1.07 (0.89–1.28), P=0.48. Among patients without MCS, allosensitization was associated with post-HTx mortality, HR: 1.19 (1.03–1.39), P=0.02. Kaplan-Meier analysis revealed equivalent survival in unmatched and matched cohorts when comparing MCS patients who were allosensitized and non-sensitized MCS patients. Among non-MCS patients, allosensitization was associated with worse survival in both unmatched and matched analysis. Conclusions MCS was associated with allosensitization. For MCS patients, allosensitization did not independently predict worse post-HTx outcome. Among non-MCS patients, allosensitization was associated with worse post-HTx survival. Allosensitization appears to be a heterogeneous process influenced by presence of MCS.

Ventricular assist device elicits serum natural IgG that correlates with the development of primary graft dysfunction following heart transplantation

“…VAD implants have previously been associated with presensitization to HLA in adults [2] [4] [13] [14] [15] and pediatric patients [16]. Presensitization to HLA is an important barrier to transplantation with sensitized patients experiencing longer wait times for suitable organs and higher waiting list mortality rates [15].…”

Pig-to-human heart transplantation: Who goes first?

“…Indeed, adverse events associated with long‐term VAD support (device thrombosis, thromboembolism, gastrointestinal hemorrhage, and infectious complications related to drive lines) all factor in the current scheme for establishing priority for allocation of scarce heart allografts. Additionally, the presence of, or development of, “panel‐reactive antibodies” (PRA) against human leukocyte‐associated (HLA) antigens (allosensitization) is closely associated with prior mechanical circulatory system device placement and prior blood product exposure, 21 and is associated with worse outcomes after heart transplantation 22 . Identifying a negative cross‐matched organ for highly sensitized patients is difficult, by definition.…”

Consideration of appropriate clinical applications for cardiac xenotransplantation

“…[40][41][42][43] The development of allosensitization is linked to prior allografts, and blood transfusions, and its management remains a significant challenge. [40][41][42][43] The development of allosensitization is linked to prior allografts, and blood transfusions, and its management remains a significant challenge.…”

“…The development of antibodies against human and nonhuman leukocyte antigens (allosensitization) has been associated with worse outcomes in transplant candidates. [40][41][42][43] The development of allosensitization is linked to prior allografts, and blood transfusions, and its management remains a significant challenge. [44][45][46][47] With an already inadequate supply of organs, procuring a suitable crossmatched organ for those highly sensitized is a difficult proposition.…”