Introduction: ECP is an established therapy for prevention of acute rejection perioperatively and for treatment of recurrent, therapy resistant rejections after heart transplantation (HTx). Data on cardiac allograft vasculopathy (CAV) prevention with ECP exist. There is no data on treatment with ECP immediately postoperative in HTx patients to achieve CNI delay and avoidance of induction therapy. Here we report our first experience on 3 patients that were successfully treated with ECP immediately postoperative to reduce the risk of sepsis or cancer recurrence.
Case Report: 3 patients underwent ECP with CNI delay after HTx due to high risk for cancer recurrence (n=2) or sepsis (n=1). All patients were female. Patient 1 (46 years at time of transplantation) was transplanted urgently with a progressive cardiac sarcoma (myxofibrosarcoma). Patient 2 (43y) had a history of osteosarcoma with pulmonary metastasis (20 years before HTx) and breast cancer (10 and 7 years before HTx). Patient 3 (33y) was transplanted in a high-urgent status after aortic dissection followed by complications and finally needed ECMO support and high dosage of catecholamines. All patients received postoperative ECP (10 treatments within first month, every 2 weeks in month 2+3, 1/month until month 6) with low maintenance immunosuppression with tacrolimus (target range 7-10ng/ml in month 1-3, 5-10ng/ml >3 months), mycophenolate mofetil for 2-3 weeks (2mg/day), everolimus after week 2-3 (target range: 3-8ng/ml) and steroids (0.2mg/kg starting on day 7, tapering to 0.03 mg/kg until end of first year). All patients are alive with excellent graft function 13, 8 and 5 months after HTx, respectively. Out of 13 biopsies (3, 6 and 4, respectively), 2 showed mild signs of cellular rejection (ISHLT 1A/1R): In patient 1, 13 days and in patient 3, 23 days after HTx. No signs of antibody-mediated rejection (ABMR) with C4d or C3d positivity were found. Moreover, non of the patients developed clinical infection during the first 6 months post transplantation. In both patients with history of cancer, no reoccurrence developed.
Summary: CNI delay with better survival in the ECP group was described in LTx patients but there is no evidence for HTx patients. In our experience, CNI delay and avoidance of induction therapy due to ECP is a safe and effective strategy for patients at risk for cancer recurrence or sepsis.