Livia A. Goldraich, Santiago A. Tobar Leitão, Fernando L. Scolari, Fabiana G. Marcondes-Braga, Marcely G. Bonatto, Dipika Munyal, Jennifer Harrison, Rafaela V.P. Ribeiro, Estela Azeka, Diogo Piardi, Maria R. Costanzo and Nadine Clausell* Pages 3351 - 3384 ( 34 )
Heart transplantation is the standard of therapy for patients with end-stage heart disease. Since the first human-to-human heart transplantation, performed in 1967, advances in organ donation, surgical techniques, organ preservation, perioperative care, immunologic risk assessment, immunosuppression agents, monitoring of graft function and surveillance of long-term complications have drastically increased recipient survival. However, there are yet many challenges in the modern era of heart transplantation in which immunosuppression may play a key role in further advances in the field. A fine-tuning of immune modulation to prevent graft rejection while avoiding side effects from over immunosuppression has been the vital goal of basic and clinical research. Individualization of drug choices and strategies, taking into account the recipient's clinical characteristics, underlying heart failure diagnosis, immunologic risk and comorbidities seem to be the ideal approaches to improve post-transplant morbidity and survival while preventing both rejection and complications of immunosuppression.
The aim of the present review is to provide a practical, comprehensive overview of contemporary immunosuppression in heart transplantation. Clinical evidence for immunosuppressive drugs is reviewed and practical approaches are provided. Cardiac allograft rejection classification and up-to-date management are summarized. Expanding therapies, such as photophoresis, are outlined. Drug-to-drug interactions of immunosuppressive agents focused on cardiovascular medications are summarized. Special situations involving heart transplantation such as sarcoidosis, Chagas diseases and pediatric immunosuppression are also reviewed. The evolution of phamacogenomics to individualize immunosuppressive therapy is described. Finally, future perspectives in the field of immunosuppression in heart transplantation are highlighted.
Heart transplantation, immunosuppression, clinical management, rejection, drug interactions, pharmacogenomics.
Heart Transplantation Unit, Cardiology Department, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Cardiovascular Research Laboratory, Experimental Research Center, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul. Porto Alegre, Cardiovascular Research Laboratory, Experimental Research Center, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul. Porto Alegre, Heart Institute (InCor-HC.FMUSP), University of Sao Paulo, Sao Paulo, Heart Failure Center, Heart Transplantation Program, Hospital Santa Casa de Misericórdia, Curitiba, Multiorgan Transplant, University Health Network, Toronto General Hospital, Toronto, Multiorgan Transplant, University Health Network, Toronto General Hospital, Toronto, Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, Toronto, Heart Institute (InCor-HC.FMUSP), University of Sao Paulo, Sao Paulo, Post-graduation Program in Medical Science: Cardiology and Cardiovascular Science, Federal University of Rio Grande do Sul, Porto Alegre, Heart Failure Research, Advocate Heart Institute, Medical Director, Edward Hospital Center for Advanced Heart Failure, Naperville, Illinois, Post-graduation Program in Medical Science: Cardiology and Cardiovascular Science, Federal University of Rio Grande do Sul, Porto Alegre