Immunoadsorption in idiopathic dilated cardiomyopathy, a 3-year follow-up (original) (raw)
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Journal of the American College of Cardiology, 2000
The objective of our study was to assess the hemodynamic effects of immunoadsorption (IA) and subsequent immunoglobulin G (IgG) substitution in comparison with the effects of conventional medical treatment in patients with dilated cardiomyopathy (DCM). BACKGROUND Various circulating cardiac autoantibodies have been detected among patients suffering from DCM. These antibodies are extractable by IA. METHODS Patients with DCM (n ϭ 18, New York Heart Association III-IV, left ventricular ejection fraction Ͻ30%) and who were on stable medication participated in the study. Hemodynamic measurements were performed using a Swan-Ganz thermodilution catheter. The patients were randomly assigned either to the treatment group with IA and subsequent IgG substitution (IA/IgG group, n ϭ 9) or to the control group without IA/IgG (n ϭ 9). In the IA/IgG group, the patients were initially treated in one IA session daily on three consecutive days. After the final IA session, 0.5 g/kg of polyclonal IgG was substituted. At one-month intervals, IA was then repeated for three further courses with one IA session daily on two consecutive days, until the third month. RESULTS After the first IA course and IgG substitution, cardiac index (CI) increased from 2.1 (Ϯ0.1) to 2.8 (Ϯ0.1) L/min/m 2 (p Ͻ 0.01) and stroke volume index (SVI) increased from 27.8 (Ϯ2.3) to 36.2 (Ϯ2.5) ml/m 2 (p Ͻ 0.01). Systemic vascular resistance (SVR) decreased from 1,428 (Ϯ74) to 997 (Ϯ55) dyne⅐s⅐cm Ϫ5 (p Ͻ 0.01). The improvement in CI, SVI and SVR persisted after three months. In contrast, hemodynamics did not change throughout the three months in the control group.
Immunoadsorption for the Treatment of Dilated Cardiomyopathy
ASAIO Journal, 2006
Objectives: Patients before implantation of a VAD and on support often experience repeated episodes of heparinization. This may predispose to develop HIT. We assessed the occurrence of this disease and the influence on clinical outcome in patients after implantation of a VAD. Methods: Retrospective analysis of data between the years 2000 and 2005. Patients were divided into three groups: those without confirmed HIT (non HIT), those in whom the diagnosis of HIT was made before VAD implantation (HIT pre) and those who developed HIT after VAD implantation (HIT post). Endpoints assessed were procedural success, as defined by discharge from hospital or transplantation or recovery of the failing heart. Results: The data of 358 consecutive patients were analyzed. There were 330 non HIT patients (91.6%) compared to 15 HIT pre patients (4.5%) and 13 HIT post patients (3.9%). Procedural success was observed in 51% of non HIT patients, 67% of HIT pre patients and 31% of HIT post patients. In the non HIT patients 49% died before achieving success compared to 33% in HIT pre patients and 69% in HIT post patients. Conclusion: HIT is a frequent complication in VAD patients and associated with detrimental outcome when diagnosed after implantation. Timely diagnosis of HIT and the implementation of alternative anticoagulation procedures improves results. Screening programs for HIT before and after VAD implantation and immediate implementation of an alternative anticoagulation regimen may improve outcome.
Circulation, 2001
Background-Immunoadsorption (IA) and subsequent immunoglobulin (Ig) G substitution represent an additional therapeutic approach in dilated cardiomyopathy (DCM). It remains to be elucidated whether this treatment modulates myocardial inflammation, which is possibly a causal factor of ventricular dysfunction. Methods and Results-From 25 DCM patients (EF Ͻ30%), 12 patients were randomized for IA therapy and subsequent IgG substitution at 1-month intervals until month 3. Before (Ͻ7 days) and after IA therapy, right ventricular biopsies were obtained from all patients. Biopsies were also obtained at intervals of 3 months from 13 patients without IA/IgG treatment (controls). IA/IgG treatment induced improvement in left ventricular ejection fraction from 21.3Ϯ1.7% (ϮSEM) to 27.0Ϯ1.3% (PϽ0.01 versus baseline/controls) and reduction of the -receptor autoantibody serum levels (PϽ0.01 versus baseline/controls). The number of CD3 cells decreased from 5.7Ϯ0.8 to 2.9Ϯ0.5 cells/mm 2 (PϽ0.01 versus baseline/controls). This decline was paralleled by a decrease in CD4 (PϽ0.01 versus baseline/controls) and CD8 (PϽ0.05 versus baseline/controls) lymphocytes. The number of leukocyte common antigen-positive cells (leukocytes) was reduced from 20.0Ϯ3.2 to 9.9Ϯ2.8 cells/mm 2 (PϽ0.01 versus baseline/PϽ0.05 versus controls). HLA class II expression decreased from 2.1Ϯ0.7% to 1.1Ϯ0.4% (PϽ0.05 versus controls/baseline). The number of immunopositive cells and the expression of HLA class II in controls remained stable. In both groups, the degree of fibrosis remained unchanged.
Removal of autoantibodies in dilated cardiomyopathy by immunoadsorption
International Journal of Cardiology, 1996
Immunoadsorption with Ig-Therasorb leads to a marked decrease in serum levels of immunoglobulins including of the agonist-like anti-p,-adrenoceptor autoantibody found in the serum of patients with idiopathic dilated cardiomyopathy. The reduction in autoantibody levels was accompanied by an improvement of heart function and a shift to a lower NYHA state. In this disease, as in a variety of other autoimmune disorders, apheresis with Ig-Therasorb led to a rapid improvement of the clinical status and could be used in end-stage dilated cardiomyopathy (with autoantibodies) as a bridge for transplantation.
The Journal of Heart and Lung Transplantation, 2004
We assessed the efficiency of non-specific extracorporeal immunoadsorption (EIA), using polyclonal anti-human immunoglobulin antibodies, in depleting the serum of anti-galactose␣1,3galactose (Gal) antibody and in decreasing serum cytotoxicity in 5 patients with idiopathic dilated cardiomyopathy. The mean concentrations of anti-Gal immunoglobulin (Ig)M and IgG before EIA were 74 g/ml and 159 g/ml, respectively. After EIA, these concentrations decreased by 86% and 88%, respectively. Both anti-Gal IgM and IgG returned to pre-EIA concentrations within 1 month, without rebound to greater than baseline concentrations. After EIA, mean serum cytotoxicity also decreased from 90% to 17%, with recovery by 1 month. Extracorporeal immunoadsorption proved safe in patients with heart failure and was effective in depleting anti-Gal antibody and in decreasing serum cytotoxicity to pig cells.
A pilot study to assess the use of protein a immunoadsorption for chronic dilated cardiomyopathy
Journal of Clinical Apheresis, 2007
Dilated cardiomyopathy (DCM) is a leading cause of end-stage heart failure and cardiac transplantation. Anticardiac antibodies are common and removal of these through immunoadsorption (IA) is associated with improvement in global cardiac function. The effect of IA on regional function and quality of life (QOL) without intravenous immunoglobulin (IVIG) substitution has not been described. We performed a pilot trial using Immunosorba 1 columns in four patients with chronic DCM and NYHA Class II-III congestive heart failure. Subjects were followed for 6 months with serial echocardiograms and validated QOL assessments. Regional and global left ventricular (LV) end-systolic deformations were assessed by two-dimensional strain echocardiography. Total IgG decreased 95% (from 1,210 AE 274 mg/dl to 57 AE 16 mg/dl, P ¼ 0.003) and IgG3 decreased 61% (from 33 AE 16 mg/dl to 13 AE 7 mg/dl, P ¼ 0.024). QOL improved from baseline to 6 months as assessed by the Living with Heart Failure questionnaire (from 54 AE 18 to 19 AE 7, P ¼ 0.029). Mean LV ejection fraction improved from 35 to 40% at Day 5 and to 44% at 6 months (P ¼ NS). The LV end diastolic and end systolic volumes decreased (220-202 ml, 159-130 ml, P ¼ NS) at 6 months. Global end-systolic strain improved from À7.3% at baseline to À8.5% at Day 5 and À8.8% at 6 months (P ¼ NS). Regional LV function and response to IA was not uniform. Even without IVIG substitution, IA for the treatment of chronic DCM is associated with improved QOL up to 6 months after treatment. A randomized, sham-controlled trial is required to confirm the benefits of IA for DCM. J. Clin. Apheresis 22:210-214, 2007. V V C 2007 Wiley-Liss, Inc.
Circulation, 2001
Background-Previous studies have shown disappointing results for immunosuppressive treatment in patients with dilated cardiomyopathy. Therefore, we studied the effectiveness of such therapy in patients with HLA upregulation on biopsy. Methods and Results-Of 202 patients with dilated cardiomyopathy, 84 patients with increased HLA expression were randomized to receive either immunosuppression or placebo for 3 months; they were then followed for 2 years. After 2 years, there were no significant differences in the primary end point (a composite of death, heart transplantation, and hospital readmission) between the 2 study groups (22.8% for the immunosuppression group and 20.5% for the placebo). The secondary efficacy end point included changes in ejection fraction, end-diastolic diameter, end-diastolic volume, end-systolic volume and NYHA class; left ventricular ejection fraction increased significantly in the immunosuppression group compared with the placebo group (95% CI, 4.20 to 13.12; PϽ0.001) after 3 months of follow-up. The early favorable effects of immunosuppressive therapy on left ventricular volume, left ventricular diastolic dimension, and New York Heart Association class were also present. This improvement was maintained in the immunosuppression group at 2 years (ejection fraction: 95% CI, 6.94 to 19.04; PϽ0.001). In addition, on the basis of the protocol-specified definition of improvement, 71.8% patients in the immunosuppression group versus 20.9% patients in the placebo group met the criteria of improvement after 3 months (PϽ0.001). At the end of the follow-up period, 71.4% patients from the immunosuppression group versus 30.8% patients from the placebo group were improved (Pϭ0.001).
The American Journal of Cardiology, 1989
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