176 Late CMV Infection Complicates Heart Transplantation after Extended Duration Prophylaxis (Proph) with Valganciclovir (VGC)

Abstracts

S65 treated with IV gancyclovir. HGG was detected after transplantation and defined as serum IgG ⬍600 mg/dl (determined by nephelometry). IVIGprotocol: non specific 5% pasteurized IVIG product (Flebogamma) at a dose of 300-400 mg/kg/month was associated to antiviral therapy. Goal: to reach normal IgG levels (⬎700 mg/dl). Rate of infusion: 0.01 to 0.04 ml/kg/min. Results: Decreased levels of serum IgG were observed in IVIG-treated patients as compared with controls before-HT (932 vs 1280 mg/dl, 2-tailed Student=s T-test, p⫽0.029), at 7d (579 vs 774, p⫽0.001), 1m (491 vs 676, p⬍0.001) and at the time of CMV infection [455 vs 686 (mean one-month post-transplant IgG levels in controls), p⬍0.001]. After IVIG therapy, IgG concentrations were similar in both groups at 3m (681 vs 716, p⫽0.49) and 6m (775 vs 775, p⫽0.98). IgG levels were higher in IVIG treated patients at 12 months after HT (1023 vs 887, p⫽0.049). An increase of IgG1 and IgG3 subclasses as well as of specific anti-CMV titers was observed after IVIG-therapy. IgA concentrations remained lower in CMV-infected patients at 3 and 6m after HT. CMV antigenemia became negative after IVIG treatment in all patients. Conclusions: IVIG was associated with humoral immunity restoration in heart recipients with post-transplant HGG and CMV infection. 176

CAV-free survival during a follow-up of 10 years was significantly higher within No CMV compared to CMV disease (p⫽⬍ 0.001) and CMV infection (p⫽0.018)

Conclusions: Long time survival and CAV-free survival is significantly reduced in patients with CMV disease and infection compared to patients without CMV. 175 Humoral Immunity Reconstitution after Intravenous Immunoglobulin Replacement Therapy in Heart Recipients with Post Transplant IgG Hypogammaglobulinemia and CMV Infection J. Carbone,1 N. Del Pozo,1 J. Rodriguez-Molina,1 J. Navarro,1 A. Gallego,1 J. Fernandez-Yañez,2 J. Palomo,2 P. Muñoz,3 E. Sarmiento.1 1Clinical Immunology, Gregorio Marañon Hospital, Madrid, Spain; 2Cardiology, Gregorio Marañon Hospital, Madrid, Spain; 3Microbiology, Gregorio Marañon Hospital, Madrid, Spain. Purpose: CMV infection remains a cause of death in heart transplantation (HT). IgG hypogammaglobulinemia is a risk factor of this complication. We assessed IgG immune reconstitution after inespecific intravenous immunoglobulin (IVIG) replacement therapy for secondary IgG hypogammaglobulinemia (HGG) in heart recipients with post-transplant CMV infection. Methods and Materials: 32 HT patients with secondary HGG who developed post-transplant CMV infection and received IVIG (IVIG-group) and 47 heart recipients without severe infectious complications after-transplantation (control group) were studied. CMV infection was demonstrated by antigenemia and PCR. All CMV-infected patients had been previously

Late CMV Infection Complicates Heart Transplantation after Extended Duration Prophylaxis (Proph) with Valganciclovir (VGC) V. Stosor,1,2 M. Angarone,1 E. McGee,3 G. Ferguson,4 J. Kruse,4 E. Schupbach,4 K. Grady,3 M.G. Ison,1,2 W. Cotts.3 1Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL; 2 Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL; 3Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL; 4 Northwestern Memorial Hospital, Chicago, IL. Purpose: CMV is a significant complication post HT, even with standard durations (3 mo) of antiviral proph. Optimal duration of CMV proph has not been established. We examined CMV outcomes after extended proph with VGC. Methods and Materials: Retrospective study of HT recipients (recip) from June 05-Dec 08 was undertaken to determine incidence and features of CMV infection after ⬍12 mo v. ⱖ12 mo of VGC proph. Results: 663 CMV D⫹ and/or R⫹ HT recip were mean age⫽54.9 y, male (70%) and Caucasian (73%). The majority (76%) received basiliximab followed by FK, MMF, and prednisone. CMV status was 29% D⫹/R-, 38% D⫹/R⫹, and 33% D-/R⫹. 34 (54%) received ⬍12 mo VGC proph (mean⫽192 d) compared to 29 (46%) who had ⱖ12 mo VGC (mean⫽415 d, p⬍.001). CMV D⫹/R- recip were more likely to receive ⱖ12 mo VGC (p⫽ .052). CMV occurred in 21%, with incidence of 56% and 13% in CMV D⫹/R- and D⫹/R⫹ recip. Later onset of CMV occurred in those with ⱖ12 mo VGC (457d v. 249 d post HT, p⫽.002). Time from proph discontinuation to onset of CMV was 72d v. 88d after ⬍12 mo v. ⱖ12 mo VGC (p⫽ .478). CMV infection was associated with CMV D⫹ (p⫽.01) and CMV D⫹/R- (p⬍.001) status but not thymoglobulin induction (p⫽1.00), rejection (p⫽1.00), or VGC proph duration (p⫽.973). There was no difference in incidence of CMV (18% v. 24%, p⫽.550), invasive CMV disease (0% v. 13%, p⫽1.00), degree of viremia (30,033 v. 24,390 copies/ mL), hospitalization for CMV (50% v. 43%, p⫽1.00) or mortality (18% v. 10%, p⫽.488) in those who had ⬍12 mo v. ⱖ12 mo of VGC proph. There were no CMV relapses or infectious deaths. Conclusions: Extending duration of VGC proph ⱖ12 mo did not reduce late CMV disease in HT recip. After extended duration proph, CMV D⫹/R- recipients are at high risk for late CMV infection within 3 mo of proph discontinuation. In this cohort, CMV infection was limited to mildmoderate disease. The full impact of prolonged CMV proph on the epidemiology of CMV disease, emergence of antiviral resistance, and antiviral toxicities requires further study. 177 More Formal Training Needed for Emergency Medical Services Technicians on Left Ventricular Assist Device K. Hryniewicz,1 P. Satterle,2 B. Cabuay,1 D. Feldman,1 E. Shao,1 B. Unger,1 B. Sun,1 N. Moazami.1 1Minneapolis Heart Institute,