Marcus Anthony Urey

Transthyretin (TTR) amyloidosis (ATTR) is a progressive, systemic disease caused by misfolded TTR (variant [hereditary] or wild type) that aggregates into amyloid fibrils, which then deposit into o...

Background: Endomyocardial biopsies (EMB) remain the reference standard for detection of acute rejection in heart transplant (HTx) patients. Recent studies evaluating novel noninvasive tests have sparked a renewed discussion in the HTx community about revising acute rejection surveillance policies. However, patient and provider perspectives remain underexplored. This single‐center study examined both HTx patient and provider perspectives on replacing EMBs earlier with noninvasive blood tests. Methods: We performed semi‐structured interviews with 28 HTx patients to explore their perspectives on replacement of EMBs with donor‐derived cell‐free DNA (dd‐cfDNA) early post‐HTx. We subsequently conducted a survey of 118 HTx patients using self‐administered online questionnaires. We also performed semi‐structured interviews with 18 HTx providers to explore their perspectives. Thematic analysis was performed on interview and open‐ended survey responses using deductive and inductive approaches. Patient quantitative survey responses were analyzed with descriptive statistics. Results: Our study identified three key themes: patient anxiety related to EMBs, importance of patient‐provider communication, and strong interpersonal trust in providers by HTx patients. Although 78.4% of patients experienced EMB‐related anxiety, they prioritized testing accuracy to ensure “the health of their new heart.” Consequently, patients favored the most accurate testing protocol and trusted providers to make this decision (91.1%). HTx providers raised concerns about the accuracy and safety of noninvasive surveillance testing for high‐risk patients. Conclusion: HTx patients trusted their providers to determine the most accurate acute rejection surveillance policy. Additionally, our study provides important patient‐centered priorities to guide the implementation of early noninvasive testing into clinical practice. Trial Registration : ClinicalTrials.gov identifier: NCT06414603

The prevalence of adult congenital heart disease (ACHD) is increasing, with heart failure being the leading cause of death. For many ACHD patients, heart transplantation is the only treatment option for advanced heart failure, though significant extracardiac involvement may require multi-organ transplantation. Despite the rising number of ACHD transplants, multi-organ transplants in this population remain challenging, and a substantial gap remains between those in need and those who receive a transplant. While short-term outcomes may be worse for ACHD patients, long-term outcomes are comparable and even superior to other cardiomyopathies. Extracardiac organ dysfunction is common in ACHD patients, often precluding heart-alone transplantation. Fontan-associated liver disease, pulmonary vascular and restrictive lung disease, and renal dysfunction frequently necessitate multi-organ transplantation. ACHD patients have a unique immunological and sensitization profile, increasing their risk for infection, rejection, and malignancies, requiring specialized pretransplant desensitization and post-transplant immunosuppression strategies. ACHD transplantation presents unique surgical challenges, including chest reentry, vascular access issues, bleeding risks, extensive anatomical reconstruction, the need for longer vascular segments from donors, and prolonged ischemic times. Decisions regarding heart-alone versus heart-liver, heart-lung, or heart-kidney transplantation demand careful evaluation. These complex surgical plans require extensive multimodal imaging and collaboration with ACHD cardiac imaging specialists and abdominal transplant teams. Comprehensive coordination and psychosocial support are crucial for ACHD patients throughout the transplant process. A dedicated multidisciplinary team and an established and separate pathway for pre-, peri-, and postoperative care in centers with ACHD and multi-organ transplant expertise are essential. There is need for a revised organ allocation system to ensure timely access to transplantation for ACHD patients.

Background: Endomyocardial biopsies (EMB) remain the reference standard for detection of acute rejection in heart transplant (HTx) patients. Recent studies evaluating novel noninvasive tests have sparked a renewed discussion in the HTx community about revising acute rejection surveillance policies. However, patient and provider perspectives remain underexplored. This single-center study examined both HTx patient and provider perspectives on replacing EMBs earlier with noninvasive blood tests. Methods: We performed semi-structured interviews with 28 HTx patients to explore their perspectives on replacement of EMBs with donor-derived cell-free DNA (dd-cfDNA) early post-HTx. We subsequently conducted a survey of 118 HTx patients using self-administered online questionnaires. We also performed semi-structured interviews with 18 HTx providers to explore their perspectives. Thematic analysis was performed on interview and open-ended survey responses using deductive and inductive approaches. Patient quantitative survey responses were analyzed with descriptive statistics. Results: Our study identified three key themes: patient anxiety related to EMBs, importance of patient-provider communication, and strong interpersonal trust in providers by HTx patients. Although 78.4% of patients experienced EMB-related anxiety, they prioritized testing accuracy to ensure “the health of their new heart.” Consequently, patients favored the most accurate testing protocol and trusted providers to make this decision (91.1%). HTx providers raised concerns about the accuracy and safety of noninvasive surveillance testing for high risk patients. Conclusion: HTx patients trusted their providers to determine the most accurate acute rejection surveillance policy. Additionally, our study provides important patient-centered priorities to guide the implementation of early noninvasive testing into clinical practice.

Background The reference standard of detecting acute rejection (AR) in adult heart transplant (HTx) patients is an endomyocardial biopsy (EMB). The majority of EMBs are performed in asymptomatic patients. However, the benefit of diagnosing and treating AR compared to the risk of EMB complications has not been compared in the contemporary era (2010-current). Objectives This study compared treated AR and EMB complications in HTx patients. Methods The authors retrospectively analyzed 2,769 EMB obtained in 326 consecutive HTx patients between August 2019 and August 2022. Variables included surveillance versus for cause indication, recipient and donor characteristics, EMB procedural data and pathologic grades, treatment for AR, and clinical outcomes. Results The overall EMB complication rate was 1.6%. EMBs performed within 1 month after HTx compared to after 1 month HTx showed significantly increased complications (OR = 12.74, p < 0.001). The treated AR rate was 14.2% in the for cause EMBs and 1.2% in the surveillance EMBs. We found the benefit/risk ratio was significantly lower in the surveillance compared to the for cause EMB group (OR = 0.05, p < 0.001). Conclusions The yield of surveillance EMBs has declined in the contemporary era, while for cause EMBs continued to demonstrate a high benefit/risk ratio. The risk of EMB complications was highest within 1 month after HTx. Surveillance EMB protocols in HTx patients may need to be re- evaluated.