*Purpose: Extracorporeal photopheresis (ECP) is an established therapy for treatment of heart transplant rejection and is also applied for rejection prevention in the perioperative setting after heart transplantation (HTX). Recently we started a new protocol with avoidance of antibody induction therapy and delay of calcineurin inhibitor (CNI) in high risk patients after HTX incorporating ECP as rejection prophylaxis.

*Methods: We report our first experience on 20 patients that were treated according to this protocol. Inclusion criteria were: history of cancer (n=5), bridge to transplant via extracorporeal membrane oxygenation (ECMO) (n=5) and ten patients had infections within one month before HTX. Two patients were combined heart-kidney transplants. None of the patients received antithymocyte globuline (ATG) as induction therapy. Immunosuppression consisted of low dose tacrolimus (target range 7-10ng/ml in month 1-3, 5-10ng/ml >3 months) with a delayed start (2 to 7 days post HTX) mycophenolate mofetil (MMF: 2mg/day), and steroids (0.2mg/kg starting on day 7, tapering to 0.03 mg/kg until end of first year). 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 and whenever, there were clinical signs of acute rejection.

*Results: Seventeen of 20 (85%) patients are alive with excellent graft function after a median follow-up of 11,5 (range, 1 – 38) months after HTX. Three patients (15%) showed biopsy proven signs of cellular rejection. Two were successfully treated with iv steroids and one developed steroid resistant rejection and received ATG therapy. One patient showed AMR 1i in a biopsy and received ivIg therapy. All rejections showed no signs of hemodynamic compromise. Three patients developed severe pneumonia (bacterial n=1, fungal n=2), and one a non-sternal wound infection Both patients that developed fungal pneumonia had ECMO support after transplant due to primary graft dysfunction. Both died three weeks and 1,5 months post transplant due to multiorgan failure. One patient with history of cancer showed recurrence of disease and died 13 months after transplantation due to disease progression.

*Conclusions: Up to now this is the first report on prophylactic ECP with avoidance of induction therapy and CNI delay in HTX patients. Severe infectious complications remain a problem in this high-risk group and occur in approximately 20%. However, ECP is a safe and effective strategy for patients at risk for cancer recurrence or sepsis to avoid organ rejection.

« Back to 2020 American Transplant Congress