Cytomegalovirus infection prophylaxis following heart transplantation: comparison of two regimes

The Journal of Heart and Lung Transplantation Volume 20, Number 2 88 PREVALENCE AND OUTCOME OF HEPATITIS B VIRUS (HBV) INFECTION FOLLOWING THORACIC ORGAN TRANSPLANTATION P. Grossi, D. Dalla Gasperina, M. Furione, E. Zerrilli, B. Nocita, G. Spoladore, M. Vigano `, L. Minoli, IRCCS Policlinico San Matteo, Pavia, Italy Reactivation of hepatitis B virus (HBV) infection is known to occur in chronic HBsAg carriers who are immunosuppressed. From November 1985 through September 2000 a total of 786 recipients (160 female and 626 male, mean age 47.6, range 8-71 years) underwent thoracic organ transplantation (612 heart, 29 heart-lung, 70 double lung and 75 single lung) at our Institution. Twenty-one HbsAg positive, HBV-DNA negative patients underwent thoracic organ transplantation (15 heart and 6 lung). Nine (42.8%) patients died of HBV unrelated causes at a mean of 33.1 (median 17.6, range 0.167-107.3) months after transplantation, two are still alive with HBV-DNA negativity and 10 (47.6%) developed HBV reactivation, documented by HBV-DNA detection on peripheral blood, at a mean of 31.5 (median 20.7, range 0.133-129.5) months after transplantation. Of these 10 patients two died of decompensated liver disease before lamivudine was available at 20.9 and 40.9 months after transplantation, respectively. The other 8 patients underwent a liver biopsy and were treated with lamivudine at the dose of 100 mg/day. Furthermore five patients who tested negative for HBV markers and one who was HBsAb and HBcAb positive prior to transplantation were found HBV-DNA positive at a mean of 37.6 (median 25.1, range 9.5-120.6) months after transplantation and two of them were treated with lamivudine. Five of the 10 lamivudine treated patients cleared HBV-DNA from blood and the mean time to HBV-DNA clearance was 53.2 (range 31-83) days after the start of lamivudine treatment. Serum ALT returned to normal in 5/7 patients with pre-treatment liver function tests abnormalities after a mean of 123.6 (range 31-277) days of lamivudine treatment. No significant side effect was observed during the treatment that was given for a median of 296 days (range 2-908). Thoracic organ transplantation in HBsAg positive and HBVDNA negative recipients is followed by HBV reactivation in a high percentage of cases. However, the clinical outcome and the availability of lamivudine suggest not to exclude these patients from transplantation. 89 CYTOMEGALOVIRUS INFECTION PROPHYLAXIS FOLLOWING HEART TRANSPLANTATION: COMPARISON OF TWO REGIMES H. Antretter, D. Hoefer, H. Hangler, J. Margreiter, C. Larcher, R. Margreiter, G. Laufer, The Leopold-Franzens-University of Innsbruck, Innsbruck, Austria Subject: Cytomegalovirus (CMV) infection still remains a serious problem after heart transplantation (HTX). It is associated with increased morbidity, mortality, increased incidence of acute rejection and possibly the development of transplant vasculopathy. Therefore a variety of strategies have been proposed for prophylaxis of CMV infection. Methods: From 1.1.1995 to 15.10.1999 102 orthotopic heart transplantations were performed in 101 patients. Group I (n⫽40, 1/95-12/96) received immunoglobuline (intravenously three times) and aciclovir (orally for six months) for CMV prophylaxis.

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Group II (n⫽61, 1/97-10/99) was treated with ganciclovir (intravenously for one week, orally for eleven weeks). Regarding to demographic data, immunosuppression, CMV monitoring (pp65 antigenemia test and murex hybrid capture assay) and rejection classification (ISHLT) both groups were similar. Results: In group I 19 CMV infections were diagnosed (14 asymptomatic viremias, 2 CMV syndromes, 3 CMV pneumonias) whereas in group II 13 infections (12 asymptomatic viremias, 1 CMV syndrome) occurred (p⫽0.006). Mean onset of infection was after 40 postoperative days (median 33 days) in group I and after 140 postoperative days (median 180 days) in group II (p⫽0.003). Acute rejection (grade II or higher according to ISHLT classification) was diagnosed in 21 patients of group I and in 13 patients of group II (p⫽0.003). 10 patients out of group I suffered from recurrent rejection whereas in group II no recurrent rejection occurred. Regarding other infections, postoperative complications or operations no significant differences were found. One-year-survival was 72.5% (29 patients) in group I and 91.8% (56 patients) in group II (p⫽0.001). Conclusion: The three month lasting ganciclovir prophylaxis had a significant positive impact on the incidence and onset of CMV infection as well as on clinical severity of infection. There was also a strong correlation to a smaller number of acute rejections, recurrent rejections and to a significantly higher one-year-survival rate. 90 SYNCOPE FOLLOWING ORTHOTOPIC HEART TRANSPLANTATION R.M. Sangrigoli, A. Katz, B. Sanchez, H.B. Helfeld, H. Eisen, S. Rothman, Temple University Hospital, Philadelphia, PA, USA Purpose: To identify the prevalence, etiology and prognosis in orthotopic heart transplant (OHT) recipients with syncope. Methods: Retrospective analysis of 21 out of 641 (3.3%) OHT recipients presenting with syncope (n⫽16) or severe near-syncope (n⫽5) over an 8 year period. Work-up included electrophysiologic testing and tilt table testing. Patients (pts) were also evaluated for concurrent structural heart disease (SHD) including significant rejection, LV dysfunction and coronary artery disease. Results: The etiology of syncope was determined to be a primary bradycardia (Brady) in 8 pts (5 with sinus node dysfunction and 3 with heart block) and non-bradycardic (Other) in 7 pts (ventricular tachycardia in 3 pts, supraventricular tachycardia in 1 pt, neurocardiogenic in 2 pts and carotid hypersensitivity in 1 pt). No definitive etiology (Unknown) could be determined in 6 pts. The incidence of concurrent SHD, overall survival and 24 month survival following the syncopal event are shown in the table. A bradycardic etiology of syncope was strongly associated with underlying structural heart disease compared to both Other and Unknown etiologies (P ⬍ 0.05). In addition, pts who presented with a bradycardic etiology had a higher over all mortality (p ⬍0.05) and significantly decreased 24 month survival (p ⬍ 0.005). Four of five deaths in the bradycardia group were due to graft failure and occurred at a mean of 2.3⫾1.6 months from the syncopal event. All other deaths were related to infectious complications or carcinoma and occurred at a mean of 30⫾12 months after the syncopal event. Conclusions: 1) Syncope associated with a primary bradycardia carries a poor prognosis and is frequently associated with structural heart disease. 2) Heart transplant recipients presenting with syncope who have a normal electrophysiologic study and no