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Non-invasive detection of coronary artery disease by dobutamine stress echocardiography in children after heart transplantation
The Journal of Heart and Lung Transplantation Volume 21, Number 1 cases pulmonary venous obstruction was accurately predicted by VDI on TEE. Conclusion: Pulmonary venous Doppler velocities are significantly increased in LDLT. VDI elevated beyond these ‘normal’ ranges should lead to a high index of suspicion for pulmonary vein stenosis. Elevated VDI, when associated with changing/ asymmetric perfusion imaging and protracted clinical course, should prompt further therapeutic interventions. 78 NON-INVASIVE DETECTION OF CORONARY ARTERY DISEASE BY DOBUTAMINE STRESS ECHOCARDIOGRAPHY IN CHILDREN AFTER HEART TRANSPLANTATION S. Di Filippo, M. Raboisson, F. Sassolas, A. Bozio, Pediatric Cardiology, Ho ˆpital Cardiologique Louis Pradel, Lyon, France Background: Coronary vasculopathy is the main cause cardiac graft failure. As yearly coronary angiography is invasive in children, a non-invasive method for detecting graft vasculopathy is needed. The aim of this study was to test Dobutamine-Stress Echocardiography (DSE) in a pediatric population, to assess its feasibility, safety and reliability in the detection of graft coronary artery disease. Methods: Eighteen patients, aged 2 days to 16.8 years at transplantation (mean 8.4 years) underwent 44 DSEs at a follow-up of 1.1 to 11.8 years (mean 5.1 years). Selective coronary angiography was performed for comparison. Echocardiographic recordings were obtained in 4 standard views of the left ventricle and measurements carried out within the frames of a 16-segment model. Segmental scores of contractility were obtained for each segment at each stage and a total segmental contractility index was calculated. Results: All patients reached the maximum dose-stage. No major complication occured. Maximum heart rate was 57% to 89% of predicted maximum. Maximum systolic blood pressure reached 190mmHg. Segmental scores were normal in 37 cases and abnormal in 7 cases. DSE results were concordant with angiography in 82% of the cases and discordant in 18% of the cases ( 4 negative DSEs with abnormal angiography and 2 positive DSEs with normal angiography) but there was no significant angiographic lesion with normal DSE. Conclusion: According to our study, DSE is a safe and easily feasible non-invasive method for detection of coronary vasculopathy in transplanted children. It seems to predict significant angiographic lesions but further larger studies are needed to demonstrate its reliability for detecting graft ischemia in children. 79 SEVERE OBLITERATIVE BRONCHIOLITIS IS ASSOCIATED WITH TRANSPLANT CORONARY ARTERY DISEASE IN PEDIATRIC HEART-LUNG RECIPIENTS P.D. Wearden,1 S.A. Webber,2 S.K. Gandhi,1 G.J. Boyle,2 Y.M. Law,2 S. Miller,2 P. Dickman,3 R.D. Siewers,1 F.A. Pigula,1 1 Cardiothoracic Surgery; 2Cardiology; 3Pathology, Children’s Hospital of Pittsburgh, Pittsburgh, PA Background: Acute rejection of the heart in the absence of concomitant lung rejection is thought to be uncommon in heartlung transplant (HLTx) recipients. The association between chronic rejection of the lung, obliterative bronchiolitis (OB) and
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chronic rejection of the heart, transplant coronary artery disease (TxCAD), is less well known. Methods: A retrospective review of all patients undergoing HLTx at a single institution was performed. TxCAD was correlated with OB by histologic findings in autopsy and pathology specimens. Results: Thirty-six HLTxs were performed in 34 patients since 1985. Indications included congenital heart disease with pulmonary hypertension (17/34, 50%), primary pulmonary hypertension (14/34, 41%) and primary lung disease (3/34, 9%). The mean age at transplantation was 11.6 ⫾ 1 years and the mean follow-up period was 54 ⫾ 9 months. The Kaplan-Meier 1, 3 and 5 year survival was 71%, 62% and 43% respectively. Ten patients died in the perioperative period. One patient died from pneumonia one year following transplantation. Thirteen patients died as a result of complications from OB. No patient died as a direct result of cardiac rejection. There are 10 surviving patients. The freedom from OB at 1, 3 and 5 years was 79%, 48% and 32% and survival after the diagnosis of OB was 82%, 65% and 24% at the same time intervals. None of the patients experienced acute cardiac rejection. Of the 13 patients who died as a result of OB, 9 autopsies were available. All of these specimens demonstrated severe OB. The transplanted hearts were noted to have severe (3), moderate (3), mild (2) or no (1) TxCAD. Conclusions: In pediatric HLTx recipients, acute or chronic cardiac rejection was not found in the abscence of lung rejection; thus, surveillance heart biopsy is unwarranted. While OB is the cause of the greatest late mortality, moderate to severe TxCAD was found at autopsy in two-thirds of the specimens. This finding may have important implications when evaluating patients for repeat HLTx or double lung Tx following HLTx. 80 THYMOGLOBULINE威 USE IN PEDIATRIC HEART TRANSPLANTATION F. Parisi, H. Danesi, C. Squitieri, L. Di Chiara, R.M. Di Donato, DMCCP - Transplant Unit, Bambino Ges’f9 Pediatric Hospital, Rome, Italy Introduction The efficacy of induction immunotherapy with antilymphocyte serum in reducing acute and chronic rejection has been demonstrated in children as well as adults. There are few data in the literature regarding the use of polyclonal ATGs in pediatric cardiac transplantation. We describe our single-center retrospective study on the use of Thymoglobuline in a pediatric population. Methods 31 consecutive heart tx recipients (mean age 7.8 yrs; median age 9 yrs; range: 4 m-17 yrs), who all survived surgery, were included in the study. Immunosuppression consisted of CyA (starting on day 0 and reaching a blood level of 250-300 ng/ml on day 7), Aza (2-3 mg/kg), steroids (tapered to obtain discontinuation after 1 mo). Thymoglobuline was given to all pts. as induction therapy at an age-dependent dose (1-1.5mg/kg/day between 0 and 1yr; 1.5-2 mg/kg/day 1 yr to 8 yrs; and 2.5 mg/kg/d ⬎8 yrs) and duration of treatment (1-7 days). In pts.⬍1 yr lymphocytes were maintained ⬎500/mm3. We evaluated the incidence of acute and chronic rejection, infections, PTLD, blood cell count and creatinine level over a mean follow-up of 3 yrs (range 1-7 yrs). Results 30 out of 31 pts are alive at the end of follow-up (1 death due to chronic rejection 28 mos after tx). During the first 3 months, 3 grade 3A and 10 grade 1A (Working Formulation grading system) rejection episodes occurred. All reversed after steroid treatment. Two pts, one of whom died, experienced chronic rejection. Creatinine was normal in all pts during follow-
Abstracts
83
chronic rejection of the heart, transplant coronary artery disease (TxCAD), is less well known. Methods: A retrospective review of all patients undergoing HLTx at a single institution was performed. TxCAD was correlated with OB by histologic findings in autopsy and pathology specimens. Results: Thirty-six HLTxs were performed in 34 patients since 1985. Indications included congenital heart disease with pulmonary hypertension (17/34, 50%), primary pulmonary hypertension (14/34, 41%) and primary lung disease (3/34, 9%). The mean age at transplantation was 11.6 ⫾ 1 years and the mean follow-up period was 54 ⫾ 9 months. The Kaplan-Meier 1, 3 and 5 year survival was 71%, 62% and 43% respectively. Ten patients died in the perioperative period. One patient died from pneumonia one year following transplantation. Thirteen patients died as a result of complications from OB. No patient died as a direct result of cardiac rejection. There are 10 surviving patients. The freedom from OB at 1, 3 and 5 years was 79%, 48% and 32% and survival after the diagnosis of OB was 82%, 65% and 24% at the same time intervals. None of the patients experienced acute cardiac rejection. Of the 13 patients who died as a result of OB, 9 autopsies were available. All of these specimens demonstrated severe OB. The transplanted hearts were noted to have severe (3), moderate (3), mild (2) or no (1) TxCAD. Conclusions: In pediatric HLTx recipients, acute or chronic cardiac rejection was not found in the abscence of lung rejection; thus, surveillance heart biopsy is unwarranted. While OB is the cause of the greatest late mortality, moderate to severe TxCAD was found at autopsy in two-thirds of the specimens. This finding may have important implications when evaluating patients for repeat HLTx or double lung Tx following HLTx. 80 THYMOGLOBULINE威 USE IN PEDIATRIC HEART TRANSPLANTATION F. Parisi, H. Danesi, C. Squitieri, L. Di Chiara, R.M. Di Donato, DMCCP - Transplant Unit, Bambino Ges’f9 Pediatric Hospital, Rome, Italy Introduction The efficacy of induction immunotherapy with antilymphocyte serum in reducing acute and chronic rejection has been demonstrated in children as well as adults. There are few data in the literature regarding the use of polyclonal ATGs in pediatric cardiac transplantation. We describe our single-center retrospective study on the use of Thymoglobuline in a pediatric population. Methods 31 consecutive heart tx recipients (mean age 7.8 yrs; median age 9 yrs; range: 4 m-17 yrs), who all survived surgery, were included in the study. Immunosuppression consisted of CyA (starting on day 0 and reaching a blood level of 250-300 ng/ml on day 7), Aza (2-3 mg/kg), steroids (tapered to obtain discontinuation after 1 mo). Thymoglobuline was given to all pts. as induction therapy at an age-dependent dose (1-1.5mg/kg/day between 0 and 1yr; 1.5-2 mg/kg/day 1 yr to 8 yrs; and 2.5 mg/kg/d ⬎8 yrs) and duration of treatment (1-7 days). In pts.⬍1 yr lymphocytes were maintained ⬎500/mm3. We evaluated the incidence of acute and chronic rejection, infections, PTLD, blood cell count and creatinine level over a mean follow-up of 3 yrs (range 1-7 yrs). Results 30 out of 31 pts are alive at the end of follow-up (1 death due to chronic rejection 28 mos after tx). During the first 3 months, 3 grade 3A and 10 grade 1A (Working Formulation grading system) rejection episodes occurred. All reversed after steroid treatment. Two pts, one of whom died, experienced chronic rejection. Creatinine was normal in all pts during follow-