Intraoperative Therapeutic Plasma Exchange for Sensitized Heart Transplant Candidates

Donor specific human leukocyte antigen antibodies are associated with increased risk of rejection, worse post-transplant outcomes, and longer waitlist times due to the immunological risks. Intraoperative therapeutic plasma exchange (iTPE) represents a potential strategy to mitigate the immunological risk. This study aims to evaluate the clinical outcomes associated with the use of iTPE in sensitized heart transplant recipients. This retrospective, single-center cohort study included 59 adult heart transplant recipients. Patients were categorized into three groups: those receiving iTPE (n = 20), sensitized patients without iTPE (n = 19), and unsensitized patients (n = 20). We assessed recipient survival, antibody-mediated rejection (AMR) and infection free survival, waitlist time, and length of intensive care unit (ICU) and hospital stay. The overall cohort had a median age of 58 years with predominantly female patients (61%). The iTPE group exhibited a higher percentage of donor specific antibody positive and positive flow cytometry crossmatch results. Unsensitized patients had shorter wait times, but there was no difference between the iTPE and sensitized groups. There was no statistically significant difference in ICU and hospital stay, one-year and three-year survival, and AMR-free survival among the groups. The iTPE group had the lowest infection-free survival at 1 year. In conclusion, we report that iTPE may serve as an effective adjunct to immunosuppressive therapy for higher immunological risk heart transplant recipients with comparable AMR-free survival, 1- and 3-year survival. However, increased susceptibility to infections with iTPE underscores the infection management strategies post-transplant. Larger, multi-center cohort studies are necessary.