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Clinical Features: Giant cell myocarditis (GCM) is a rare and a rapidly progressive disorder with fatal outcomes such that patients often require heart transplantation. We present a case of recurrent GCM in a transplanted patient with a history of Crohn disease requiring a novel therapeutic approach., Therapeutic Challenge: After the orthotopic heart transplantation, GCM recurred on aggressive immunosuppression over the months, which included corticosteroids, basiliximab, tacrolimus, antithymocyte globulin, and rituximab. Although combination immunosuppressive therapy containing cyclosporine and 2-4 additional drugs including corticosteroids, azathioprine, mycophenolate mofetil, muromonab, gammaglobulin, or methotrexate have shown to prolong the transplant-free survival by keeping the disease under control, its role in preventing and treating recurrence posttransplantation is unclear., Solution: We added sirolimus, a macrolide antibiotic, with properties of T- and B-lymphocyte proliferation inhibition on the above immunosuppressive treatment postrecurrence of GCM. After sirolimus initiation and continuation, the patient has remained disease free.

Background: The effect of elevated heart rate (HR) on outcomes after heart transplantation (HT) has not been well established. The aim of this study was to assess predictors of elevated HR following HT and its impact on outcomes., Methods and Results: We retrospectively evaluated 394 patients who underwent HT at 2 academic medical centers from 2005 to 2016. Patients were divided into 2 groups based on HR 1 year after HT: HR ≥95 beats/min (n = 162; 41%) and HR <95 beats/min (n = 232; 59%). Median follow-up time was 6.6 (interquartile range [IQR] 2.2-7.5) years. HR ≥95 beats/min 1 year after HT was associated with younger donor age, whereas HR <95 beats/min was associated with heavy donor alcohol use and African-American recipient race. Left ventricular (LV) end-diastolic dimension, mass, and ejection fraction were lower and E/E' higher in the HR ≥95 group at the time of the last follow up. HR ≥95 beats/min at 1 year after HT was independently associated with the development of cardiac allograft vasculopathy and increased mortality., Conclusions: HR ≥95 beats/min 1 year after HT is associated with a reduction in LV size and function, increased incidence of cardiac allograft vasculopathy, and reduced survival. Studies investigating the effect of medical HR reduction on post-HT outcomes are warranted., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Diabetes mellitus is common after orthotopic heart transplantation (OHT) due to steroid-induced hyperglycemia. Traditionally, it has been treated using parenteral insulin therapy. The use of sodium-glucose co-transporter 2 inhibitors (SGLT2i) in OHT recipients is not well established. A retrospective chart review was performed on all the patients who underwent OHT at our center to identify patients on SGT2i post OHT. Clinical outcomes pre and post SGLT2i therapy were compared using the student t-test. Out of the 455 patients who had OHT at our single institution, 26 patients were on SGLT2i post OHT (1 patient was dual organ recipient - heart and liver transplant). The baseline characteristics are reported in Table 1. The median days from OHT to initiation of SGLT2i was 780 days (range 40-4986 days), and the median duration of therapy post-OHT was 169 days (range 38-2474 days). There was a statistically significant improvement in the average hemoglobin A1c, weight, and body mass index after starting SGLT2i (Results table). There was a trend towards improving renal function. There was no incidence of systemic infection, hypoglycemia, amputation, or euglycemic diabetic ketoacidosis while on SGLT2i. Two patients were able to discontinue insulin therapy after starting SGLT2i. There was no incidence or progression of cardiac allograft vasculopathy during the therapy. Two patients experienced graft rejection (1Antibody Mediated Rejection and 1 Acute Cellular Rejection) with drop in left ventricular systolic function that recovered after appropriate treatment. SGLT2i can be used safely in OHT recipients. The renal protective mechanism of SGLT2i could be helpful to combat the nephrotoxicity of calcineurin inhibitors (CNI) used for immunosuppression and help prolong the use of CNI. Further randomized studies are required to explore the complete benefits of SGLT2i in OHT recipients [ABSTRACT FROM AUTHOR]

Cardiac allograft rejection (AR) diagnosis has historically relied on endomyocardial biopsy (EMBx) and histopathology (HP). Quantifying donor-derived cell free DNA (ddcfDNA) has recently offered a non-invasive alternative for detecting graft injury. EMBx mRNA analysis via the molecular microscope profiles (MMP) quantifies AR probability not subject to HP interpretation. Our aim was to evaluate the clinical role of MMP in cardiac transplant recipients (HTx) with positive ddcfDNA. We identified 39 patients with ddcfDNA testing and subsequent EMBx for HP (n=36) and MMP (n=39) analysis. MMP was conducted by the molecular microscope diagnostic system (MMDX™). Patients with multi-organ transplantation or coronary allograft vasculopathy were excluded. MMP, HP, echo and ddcfDNA association were assessed using logistical regression (SPSS™). Average time post-transplant was 1585 ±1435 days, average LVEF 55%, and average ddcfDNA 0.81 ± 1.1. Donor specific antibodies were present in 14/39 of patients. MMP was abnormal in 18/39 patients and correlated with ddcfDNA levels (p=0.007) and HP (p=0.05), but not with LVEF (p=0.71). MMP abnormalities included 9 antibody mediated rejection (AMR), 5 acute cellular rejection (ACR), and 4 injury patterns. By HP, biopsies were abnormal in 18/36 patients: 18 ACR (grade 1) and 1 AMR (grade 2). Abnormal HP did not correlate with ddcfDNA levels (p= 0.07). HP and MMP are often discordant, Table 1. Abnormal MMP correlated with both ddcfDNA and HP, but not with LVEF. Large prospective clinical trials are needed to define clinical outcomes from treatment strategies based on biopsy results. Multi-modality testing may be necessary to monitor cardiac transplant patients for rejection and avoid misclassification. [ABSTRACT FROM AUTHOR]