ABC | Volume 110, Nº2, February 2018

Original Article Bouabdallaoui et al Heart Transplantation for PPCM Arq Bras Cardiol. 2018; 110(2):181-187 patient to exclude other causes of HF. Twenty‑eight age‑matched female patients who underwent HT during the same period for other causes served as controls. Each PPCMpatient was matched to two female control patients depending on their age at the time of transplantation (± 5 years) and on the era of transplantation (± 6 months). Survival was assessed until last follow-up. Demographics, pre- and post-transplant datawere retrospectively collected from our institution’s computerized medical charts. Information on follow-up was obtained retrospectively by direct patient interview for those who were still alive at the time of data collection. As this was an observational study, our institutional ethics board was not involved. Post-transplant course All patients had a similar post-transplant follow-up protocol. Endomyocardial biopsies were routinely performed during the first two years following HT, then, less frequently (every 6 months for years 2 to 5, then every year beyond 5th year), unless clinical indication. Coronary angiography was first performed at one-year post transplant then every two years if normal. We considered arbitrarily graft rejection as present or non-present, regardless of its type (antibody-mediated or cell-mediated rejection) and severity. The diagnosis of cell mediated rejection was based on Stanford grading system until 1990, 15 then, on the International Society for Heart and Lung Transplantation nomenclature (ISHLT; 16 ). The ISHLT Guidelines on Antibodies‑mediated rejection (AMR) were used for the definition of AMR rejections. 17,18 We considered rejection as “characterized” in the following situations: All cell-mediated rejections of grade > or = to 1A/1R; All proven antibodies mediated rejection regardless of grade; All symptomatic rejections i.e. with hemodynamic compromise or LV dysfunction. 19 All characterized rejections triggered therapeutic interventions. Cardiac Allograft Vasculopathy (CAV) was considered in the setting of any angiographic evidence of coronary artery stenosis regardless of the need of specific treatment. 20 Infections were defined as any episode requiring hospitalization or intravenous treatment, including cytomegalovirus (CMV) infections. Immunosuppressive therapy and rejection treatments varied over time. Induction therapy involved intravenous methylprednisolone, and rabbit anti-thymocyte globulin from 1986 to 2000; and antithymocyte globulin or Basiliximab since 2000. Long-term prophylactic immunosuppressive therapy was based on calcineurin inhibitors (mostly cyclosporine), azathioprine and long-term oral corticosteroids from 1986 to 2000; and calcineurin inhibitors (cyclosporine or tacrolimus), mycophenolate mofetil and oral corticosteroids since 2000. Everolimus was not routinely used upon the study population. Of note, none of the patients in PPCM group received Bromocriptine. Statistical considerations and analysis Data are presented as the mean ± standard deviation, unless otherwise specified. Comparisons between groups for continuous variables were performed using the Student t-test or the Mann Whitney U test as appropriate. The chi-square or the Fisher exact tests were used for categorical variables as appropriate. The duration of follow up was computed using reverse the Kaplan Meier method. Survival was defined as being alive at the cut-off date for our study without the need of a retransplantation. Kaplan-Meier survival curves were constructed for the two groups and compared using the log rank test. A value of p < 0.05 was considered of statistical significance. All analyses were conducted with the use of SPSS 18.0 software (Chicago, Illinois). Results Pre-transplant characteristics Pre-transplant characteristics are summarized in Tables 1 and 2. Patients in control group were transplanted for: idiopathic dilated (n = 10, 36%), ischemic (n = 8, 28.5%), congenital (n = 1, 3.5%), restrictive (n = 2, 7.1%), valvular (n = 2, 7.1%), and anthracyclines-induced (n = 3, 10.7%) cardiomyopathies or myocarditis (n = 2, 7.1%). There were significantly more patients requiring inotropes in PPCM group (n= 9, 64% in PPCM patients vs. n = 8, 28% in controls, p = 0.03). Patients requiring hemodynamic support were indiscriminately those recently diagnosed with PPCM and readily presenting with cardiogenic shock (n = 4/9), but also those with long time known PPCM and gradually progressing to end-stage heart failure (n = 5/9). Conversely, in control group, patients requiring inotropic support were more often those who were recently (< 1year) diagnosed with HF. We found no significant difference considering African descent; the time spent on the transplant waiting list; right ventricular dysfunction; and HF severity at the time of diagnosis. No significant difference in HF treatment was noticed particularly in terms of ACE inhibitors or beta‑blockers administration, and cardiac resynchronization therapy (CRT) / internal cardioverter defibrillator (ICD) implantation rates. Regarding mechanical circulatory support (MCS) indication, no significant difference was observed. In PPCM group, one patient underwent intra-aortic balloon counterpulsation (IABP), two peripheral Extra-Corporeal Membrane Oxygenation (ECMO), one long-term Ventricular Assist Devices, and one CardioWest Total Artificial Heart implantation. In control group, two patients underwent IABP, seven peripheral or central ECMO, and two long term VADs. Graft Characteristics and Immunosuppressive treatments Graft characteristics were similar in the two groups. Mean ischemic time duration was 159 ± 12 minutes in PPCM group vs. 178 ± 13 minutes in control group. Mean age donor was 45 years for PPCM recipients and 46 years for controls. We observed no significant difference in terms of sex mismatch. As the patients were matched for transplantation period, there was no difference in immunosuppressive regimen. 182