Issue: June 2020
Disclosures: Witteles reports he served on advisory boards for Alynylam, Eidos and Pfizer. Barrett reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
May 06, 2020
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Heart transplant outcomes similar for cardiac amyloidosis, other HF causes

Issue: June 2020
Disclosures: Witteles reports he served on advisory boards for Alynylam, Eidos and Pfizer. Barrett reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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Ronald M. Witteles

Patients with cardiac amyloidosis who were carefully selected for heart transplantation had similar outcomes with those who underwent transplantation for other HF causes, according to a study published in JACC: Heart Failure.

“Our study shows that when patients with advanced cardiac amyloidosis are carefully selected, outcomes posttransplant can be excellent and were no different compared with patients who underwent heart transplantation for all other indications,” Ronald M. Witteles, MD, professor of medicine and co-director of the Amyloid Center and the Multidisciplinary Sarcoidosis Program at Stanford University Medical Center, told Healio. “Other notable findings include [that] none of our patients died due to amyloidosis or amyloidosis therapy complications. Outcomes were overall excellent both for patients with immunoglobulin light chain (AL) amyloidosis and with transthyretin (ATTR) amyloidosis.”

Transplant for amyloid cardiomyopathy

Christopher D. Barrett, MD, who was an internal medicine resident at Stanford University during most of this study and is now a cardiology fellow at the University of Colorado School of Medicine in Denver, and colleagues analyzed data from 31 patients (median age at diagnosis, 61 years; median age at transplant, 61 years; 71% men) with amyloid cardiomyopathy who underwent heart transplantation at Kaiser Permanente Santa Clara Medical Center or Stanford University Medical Center between 2004 and 2017. Patients had AL amyloidosis (n = 13) or ATTR amyloidosis (n = 18).

“For many years, there has been a stigma surrounding heart transplantation for amyloidosis because overall outcomes in patient outcomes were deemed to be inferior compared with patients transplanted for other reasons,” Witteles said in an interview. “The tricky part is that patients with end-stage cardiac amyloidosis have particularly poor outcomes without transplantation.”

Chart reviews provided information and laboratory values at baseline. Researchers evaluated patients for postoperative complications, including renal failure, bleeding, infection, rejection, graft failure, malignancy and death.

Compared with patients with AL amyloidosis and the overall transplant population, those with ATTR amyloidosis were more likely to be men (89% vs. 46%; P = .017), older (median age at diagnosis, 66 years vs. 56 years; P < .001; median age at transplant, 66 years vs. 57 years; P = .042), had longer wait times (81 days vs. 23 days; P = .01) and had worse renal function at baseline.

After transplantation, the AL and ATTR groups had similar outcomes, including renal failure (23% vs. 11%, respectively; P = .371), postoperative bleeding (15% vs. 0%, respectively; P = .085), rejection, infection or malignancy (38% vs. 33%, respectively; P = .768).

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Mortality did not differ after heart transplantation between patients with amyloid cardiomyopathy and those with other indications.

“Patients with advanced cardiac amyloidosis who are potential transplant candidates should be promptly referred to a large amyloid center, which performs heart transplants for evaluation/consideration,” Witteles told Healio. “Hopefully, this study will be a final nail in the coffin for the idea that cardiac transplantation shouldn’t be pursued in amyloidosis, particularly for AL amyloidosis.”

Future research

More research is needed in this area, according to Witteles. “While this is one of the largest single-center studies reported to date, numbers are still relatively small compared to the much larger number of patients transplanted for other indications. Updated data from other large amyloid centers around the world — from the current era of improved therapies for both AL and ATTR amyloidosis — will be very helpful to developing a complete picture of posttransplant outcomes,” Witteles said. – by Darlene Dobkowski

For more information:

Ronald M. Witteles, MD, can be reached at witteles@stanford.edu; Twitter: @ron_witteles.

Disclosures: Witteles reports he served on advisory boards for Alynylam, Eidos and Pfizer. Barrett reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.