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Ranjit John
Yoshifumi Naka
Vivek Rao
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Niloo M. Edwards
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Right arrow Mechanical Circulatory Assistance

J Thorac Cardiovasc Surg 2003;125:578-591
© 2003 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Immunologic sensitization in recipients of left ventricular assist devices

Ranjit John, MDa, Katherine Lietz, MDa, Michael Schuster, BSa, Yoshifumi Naka, MDa, Vivek Rao, MDa, Donna M. Mancini, MDb, Eric A. Rose, MDa, Craig R. Smith, MDa, Mehmet C. Oz, MDa, Niloo M. Edwards, MDa, Silviu Itescu, MDa

From the Departments of Surgerya Cardiology,b Columbia University College of Physicians and Surgeons, New York, NY.

Read at the Twenty-seventh Annual Meeting of The Western Thoracic Surgical Association, San Diego, Calif, June 20-23, 2001.

Received for publication June 28, 2001. Revisions requested Aug 28, 2001; revisions received Jan 22, 2002. Accepted for publication April 12, 2002. Address for reprints: Ranjit John, MD, Division of Cardiothoracic Surgery, Columbia Presbyterian Medical Center, Milstein Hospital Building 7-435, New York, NY 10032 (E-mail: ranjitj{at}pol.net).

Objective: Left ventricular assist device implantation is associated with an increased risk of development of circulating anti-HLA class I and II antibodies (sensitization). We investigated the impact of sensitization on posttransplantation outcomes in 105 consecutive left ventricular assist device recipients.
Methods: Five hundred twenty-one consecutive adult cardiac allograft recipients between 1992 and 1999 were retrospectively studied. Of these, 105 were supported with a left ventricular assist device. Pretransplantation and posttransplantation antibody production, time to transplantation after listing, rejection, freedom from transplant coronary artery disease, and survival were evaluated by Kaplan-Meier analysis. Among sensitized left ventricular assist device recipients, 26 were treated with a pretransplantation immunomodulatory regimen consisting of intravenous immunoglobulin and cyclophosphamide.
Results: There were no significant differences between left ventricular assist device recipients and nonbridged recipients with respect to pretransplantation demographic characteristics and ABO and HLA matching. Among left ventricular assist device recipients, 66% (69/105) were sensitized before transplantation; in contrast, only 6% (24/399) of nonbridged recipients were sensitized (P < .001). Sensitized untreated left ventricular assist device recipients had both a prolongation of waiting time to transplantation and an increased risk of acute rejection. Pretransplantation immunomodulatory therapy reduced both the increased waiting time and the increased risk of acute rejection. However, sensitization or the use of immunomodulatory therapy in left ventricular assist device-bridged recipients did not influence posttransplantation survival relative to nonbridged recipients.
Conclusions: Left ventricular assist device recipients have survival outcomes similar to those of nonbridged recipients after cardiac transplantation, despite their significantly higher immunologic risk. The reduced rate of transplantation and the increased incidence of rejection observed in sensitized left ventricular assist device recipients are prevented by immunomodulatory therapy. Sensitization will remain an important issue with increased use of left ventricular assist devices, and improved understanding of this is essential to achieve better outcomes in the management of patients with end-stage heart failure.




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