Extracorporeal Photopheresis Immediately after Heart Transplantation in High Risk Patients

Purpose Extracorporeal photopheresis (ECP) is an established therapy for treatment of heart transplant rejection. We started a protocol with avoidance of antibody induction therapy and calcineurin inhibitor (CNI) delay in high risk patients after HTX incorporating ECP as rejection prophylaxis. Methods We report our first experience on 16 patients that were treated according to this protocol. Inclusion criteria were: history of cancer (n=4), bridge to transplant via extracorporeal membrane oxygenation (ECMO) (n=4) and eight patients had infections within one month before HTX. None of the patients received antithymocyte globuline (ATG) as induction therapy. Immunosuppression consisted of low dose tacrolimus with a delayed start (2 to 7 days post HTX) mycophenolate mofetil, and steroids. ECP was applied according to the protocol published by M. Barr (NEJM 1998) on days 2+3, 5+6, 10+11, 17+18, 27+28, 2 times every other week for month 2 and 3, and 2 times every 4 weeks month 4 - 6 after HTX. Routine biopsy protocol was performed in weeks 2,3,4, Months 2,3,6 and 12. Results Fifteen of 16 (82%) patients are alive with excellent graft function after a median follow-up of 8.3 (range, 0.25 - 33) months after HTX. Two patients showed biopsy proven signs of cellular rejection. One patient (2R rejection according to histology) was treated with steroids and in another patient with (1R) immunosuppression was switched from MMF to Ev. No signs of antibody-mediated rejection (ABMR) with C4d or C3d positivity were found in regular biopsies. Two patients developed severe pneumonia and one fever of unknown origin. One patient experienced candida septicemia but had candida positive skin swabs at the ECMO cannula insertion region pre-transplant. The latter patient died one week after HTX due to multi organ failure. One patient with history of cancer showed recurrence of disease and died 12 months after transplantation due to disease progression. Conclusion This is the first report on prophylactic ECP with avoidance of induction therapy and CNI delay in HTX patients. Infectious complications remain a problem in this high risk group and occur in approximately 24%. However, ECP is a safe and effective strategy for patients at risk for cancer recurrence or sepsis to avoid organ rejection.