5-Year Outcome of Photopheresis in Heart-Transplantation with Refractory/Persistent Rejection

Abstract

Purpose Extracorporeal photopheresis (ECP) is an apheresis and photodynamic therapy that uses 8-methoxy-psolaren and ultraviolet light to modulate T-cell activity. Research has shown that ECP is an effective treatment for patients (pts) with recurrent acute cellular rejection (ACR) and antibody-mediated rejection (AMR) post-heart transplantation (HTx). We sought to assess the long-term outcome of pts placed on ECP at our single center. Methods Between 2010-2012, we assessed 235 HTx pts, 10 of which were initiated on ECP. ECP was administered for 2 days, weekly x 4 and once monthly x 5 for 6 months total therapy. Endpoints included subsequent 5-year survival, 5-year freedom from cardiac allograft vasculopathy (CAV) as defined by stenosis ≥ 30% by angiography, 5-year freedom from non-fatal major adverse cardiac events (NF-MACE: defined as myocardial infarction, congestive heart failure, percutaneous cardiac intervention, placement of pacemaker/defibrillator, stroke), 5-year freedom from any-treated rejection (ATR), ACR, and AMR. A control group that was not treated with ECP (n=225) was included. Results The average time to ECP initiation was 1.6 years post-transplant. The ECP group had an average LVEF of 40% (range 23% to 63%) pre-treatment. 8/10 patients were sensitized with a PRA ≥ 10% (range 13% to 90%). The ECP group compared to the control group had a significantly lower subsequent 5-year survival (40.0% vs 79.0%, p=0.001). 6 out of 10 pts on ECP died within 5 years. There was no difference in subsequent 5-year freedom from CAV, NF-MACE, ATR, ACR, and AMR between the groups (see table). Conclusion Heart transplant pts treated with ECP due to high risk factors have reduced long-term survival. It is not clear how much ECP benefited these pts or whether earlier treatment may have been of more benefit. The selection of pts for ECP may be key to improved outcome. Further studies are needed.