title: Quilty indicates increased risk for microvasculopathy and poor survival after heart transplantation.
abstract: BACKGROUND
  The impact of Quilty (sub-endocardial infiltration of lymphocytes) on the development of stenotic microvasculopathy and outcome after heart transplantation has not yet been evaluated.
  
  
  METHODS
  Biopsies (n = 9,713) obtained within the first post-transplant year from 873 patients (722 men, age 49.3 +/- 0.3 years) were evaluated by light microscopy (hematoxylin-eosin) for Quilty and cellular rejection (ISHLT), stenotic microvasculopathy (luminal radius:medial thickness ratio <1) and endothelial disease (core diameter:cell diameter ratio < or =1). Risk factors for stenotic microvasculopathy were analyzed by logistic regression. Overall survival and freedom from graft failure (cardiac re-transplantation, myocardial infarction and sudden cardiac death) were estimated by the Kaplan-Meier method and tested using a Cox proportional hazard model.
  
  
  RESULTS
  We found 1,830 (19%) Quilty-positive biopsies in 481 (55%) Quilty-formers and stenotic microvasculopathy in 866 (9%) biopsies of 379 (43%) patients. Evidence of Quilty (odds ratio [OR] 1.77; 95% confidence interval [CI] 1.26 to 2.57) and endothelial disease (OR 4.98; 95% 95% CI 3.31 to 7.49) indicated higher risk, whereas post-transplant statin therapy was associated with lower risk for stenotic microvasculopathy (OR 0.68; 95% CI 0.48 to 0.97). Freedom from graft failure was lower in Quilty-formers (p = 0.0060) and even worse if patients suffered from both Quilty and stenotic microvasculopathy (p = 0.0017). Both factors were confirmed in multivariate regression analysis (stenotic microvasculopathy risk ratio [RR] 1.90, 95% CI 1.23 to 2.95; Quilty RR 1.77, 95% CI 1.11 to 2.82, p = 0.0430).
  
  
  CONCLUSIONS
  Presence of Quilty indicates increased risk for stenotic microvasculopathy in biopsy early after heart transplantation. Both are associated with poor outcome due to graft failure.
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany. hiemann@dhzb.de
authors.forename: Nicola E
authors.initials: NE
authors.lastname: Hiemann
authors.forename: Christoph
authors.initials: C
authors.lastname: Knosalla
authors.forename: Ernst
authors.initials: E
authors.lastname: Wellnhofer
authors.forename: Hans B
authors.initials: HB
authors.lastname: Lehmkuhl
authors.forename: Roland
authors.initials: R
authors.lastname: Hetzer
authors.forename: Rudolf
authors.initials: R
authors.lastname: Meyer
mesh_terms: D001706:Biopsy; D003251:Constriction, Pathologic / Q000473:pathology; D004699:Endocardium / Q000166:cytology / Q000473:pathology*; D005260:Female; D006084:Graft Rejection / Q000175:diagnosis / Q000209:etiology / Q000473:pathology; D016027:Heart Transplantation / Q000401:mortality*; D006352:Heart Ventricles / Q000473:pathology; D006801:Humans; D053208:Kaplan-Meier Estimate; D008214:Lymphocytes / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D016016:Proportional Hazards Models; D012044:Regression Analysis; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D017540:Tunica Media / Q000473:pathology; D014652:Vascular Diseases / Q000175:diagnosis / Q000209:etiology* / Q000473:pathology*