Purpose: The Quilty effect is defined as the presence of a nodular endocardial infiltrate of lymphocytes in an endomyocardial biopsy (EMB), and has been described exclusively in heart transplant recipients. The purpose of this study is to investigate the correlation between Quilty lesions on EMB in pediatric heart transplant recipients with rejection and coronary vasculopathy.

Methods: We performed a retrospective review of all EMBs from pediatric heart transplant recipients at our institution transplanted between 1/1/2000–12/31/2013. Patients were divided into Quilty-positive (Q+), defined as patients with at least one Quilty lesion on EMB, or Quilty-negative (Q­-). Demographic data, graft failure, grade of acute cellular rejection (ACR), development of antibody mediated rejection and coronary vasculopathy were analyzed using the chi­-square test and survival analyses.

Results: A total of 5582 EMBs were identified in 268 pediatric heart transplant patients with a median age at transplant of 9.1 years (range 0-23.6) and follow-up of 6.0 years (IQR 3.3-9.2). A Quilty lesion was described in 17.7% of all EMBs (n=988) with 42.4% occurring within the first year post-transplant (n=419). 172 patients (64%) had at least one Quilty lesion noted on EMB with 73% of Q+ patients having >1 EMB with a Quilty lesion. Compared with Q-­ patients, Q+ patients had a higher prevalence of severe ACR (36.6% vs 6.3%, p<0.001) and coronary vasculopathy (30.2% vs 4.7%, p<0.001). Q+ patients tended to be older at the time of transplant (10.8 vs 5.5 years, p=0.005), with infants ≤12 months having the lowest rates of Q+ patients compared to those >12 months (40% vs 69.1%, p<0.001). Patients transplanted before 2008, corresponding to changes in immunosuppression protocols, were more likely to be Q+ (85% vs 41%, p<0.001). There was no difference in graft survival between Q+ and Q-­ patients (log­-rank p=0.57).

Conclusion: These findings suggest that Quilty lesions in the EMBs of pediatric heart transplant recipients is correlated with coronary vasculopathy and severe ACR. A lower prevalence of Q+ patients is found in infants and patients transplanted in the more recent era with newer immunosuppression protocols. Further research is required to investigate the mechanisms and causal relationship of Quilty lesions with these findings.

CITATION INFORMATION: Joong A, Richmond M, Stack K, Rodriguez R, McAllister J, Zuckerman W, Lee T, Law S, Addonizio L. The Quilty Effect in Pediatric Heart Transplant Recipients. Am J Transplant. 2016;16 (suppl 3).

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