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The Journal of Heart and Lung Transplantation
International Society for Heart and Lung Transplantation.

The Virtual Crossmatch at Children’s Hospital of Wisconsin – Outcomes for Predicted Positive Crossmatches

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      Purpose

      Heart transplant (HTx) in the setting of a pos crossmatch (XM) is associated with worse outcomes. Since 2004, we have used a virtual XM to evaluate organ offers. We risk stratify based on usual organ criteria (fxn, size, distance) along with the perceived pt specific wait risk and likelihood of a more favorable offer given the patient’s strength and breadth of antibodies. We describe our experience focusing on management and outcomes.

      Methods and Materials

      We reviewed records of all HTx pts at our center. PRA at HTx, wait times and XM results were recorded. We reviewed peri-op care for pts with pos XM along with outcomes: rejection and death.

      Results

      100 pts underwent HTx between 8/2004 and 8/2012. 43 were sensitized at HTx, 57 were not. Comparisons shown below (Table 1). When considering any DSA at HTx as VXM pos: 17 were VXM pos and 26 were neg. Of 17 with any DSA at HTx, 12 were flow XM pos and 5 neg. All VXM pos pts received pheresis in OR; post op B cell therapy and induction was based on flow XM results (Table 2).

      Conclusions

      A judicious virtual XM strategy can increase the chance for sensitized pts to have a neg XM with acceptable wait times. Aggressive early B cell therapy can produce excellent outcomes for highly sensitized, critically ill pts unable to wait for a neg XM. Pts with DSA at HTx but a neg flow XM may still be at risk for early AMR.
      Tabled 1Table 1. Comparision of sensitized vs non-sensitized patients
      GenderAge (years)DiagnosisWait Time (days) median (range)
      Sensitized (43)24M 56%7.114 CM, 27 CHD, 2 ReTx59 (2-1899)
      Non sensitized (57)33M 58%6.630 CM, 26 CHD, 1 Tumor38 (2-971)
      Tabled 1Table 2. Virtual Crossmatch Positive (ie + DSA) managment and outcomes
      Pheresis in ORPostop PheresisThymoRituxanCell Rej Yr 1AMR Yr 1Survival (3 yr)
      Flow XM Pos (12)12911933: 1 hyperacute (ECMO), 2 Rx Bortezomib100%
      Flow XM Neg (5)502001: POD 8 (died)60%
      2 deaths, both flow XM neg, 1 with AMR POD 8, 1 with early MSOF
      see below
      * 2 deaths, both flow XM neg, 1 with AMR POD 8, 1 with early MSOF