title: Viral endomyocardial infection is an independent predictor and potentially treatable risk factor for graft loss and coronary vasculopathy in pediatric cardiac transplant recipients.
abstract: OBJECTIVE
  This study sought to evaluate the outcome and prevalence of viral endomyocardial infection after cardiac transplantation.
  
  
  BACKGROUND
  Viral myocardial infection causes heart failure, but its role after cardiac transplantation is unclear. We hypothesized that viral infection of the cardiac allograft reduces graft survival.
  
  
  METHODS
  Between June 1999 and November 2004, 94 pediatric cardiac transplant patients were screened for the presence of viral genome in serial endomyocardial biopsies (EMBs) using polymerase chain reaction (PCR) assays. Graft loss, advanced transplant coronary artery disease (TCAD), and acute rejection (AR) were compared in the PCR-positive (n = 37) and PCR-negative (n = 57) groups, using time-dependent Kaplan-Meier and Cox regression analyses. From November 2002 to November 2004, intravenous immunoglobulin therapy (IVIG) was administered to patients with PCR-positive EMBs. The outcomes of the IVIG-treated, PCR-positive patients (n = 20) were compared with IVIG-untreated, PCR-positive patients (n = 17).
  
  
  RESULTS
  Viral genomes were detected in EMBs from 37 (39%) patients; parvovirus B19, adenovirus, and Epstein-Barr virus (EBV) were the most common. The PCR-positive group (n = 37, 25% graft loss at 2.4 years) had decreased graft survival (p < 0.001) compared with the PCR-negative group (n = 57, 25% graft loss at 8.7 years) and developed advanced TCAD prematurely (p = 0.001). The number of AR episodes was similar in both groups. On multivariate analysis, presence of viral genome was an independent risk factor for graft loss (relative risk: 4.2, p = 0.015). The time to advanced TCAD after becoming PCR-positive was longer in the IVIG-treated patients (p = 0.03) with a trend toward improved graft survival (p = 0.06).
  
  
  CONCLUSIONS
  Viral endomyocardial infection is an independent predictor of graft loss in pediatric cardiac transplant recipients. This effect appears to be mediated through premature development of advanced TCAD. IVIG therapy in this subgroup may improve survival and merits further investigation.
authors.affiliation: Department of Pediatrics (Cardiology), University of Texas Health Sciences Center, Houston, TX, USA.
authors.forename: Mousumi
authors.initials: M
authors.lastname: Moulik
authors.forename: John P
authors.initials: JP
authors.lastname: Breinholt
authors.forename: William J
authors.initials: WJ
authors.lastname: Dreyer
authors.forename: Debra L
authors.initials: DL
authors.lastname: Kearney
authors.forename: Jack F
authors.initials: JF
authors.lastname: Price
authors.forename: Sarah K
authors.initials: SK
authors.lastname: Clunie
authors.forename: Brady S
authors.initials: BS
authors.lastname: Moffett
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Kim
authors.forename: Joseph W
authors.initials: JW
authors.lastname: Rossano
authors.forename: John Lynn
authors.initials: JL
authors.lastname: Jefferies
authors.forename: Karla R
authors.initials: KR
authors.lastname: Bowles
authors.forename: E
authors.initials: E
authors.lastname: O'Brian Smith
authors.forename: Neil E
authors.initials: NE
authors.lastname: Bowles
authors.forename: Susan W
authors.initials: SW
authors.lastname: Denfield
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Towbin
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003327:Coronary Disease / Q000821:virology; D005260:Female; D016679:Genome, Viral; D006084:Graft Rejection / Q000821:virology*; D006085:Graft Survival; D016027:Heart Transplantation; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009205:Myocarditis / Q000453:epidemiology* / Q000821:virology*; D016133:Polymerase Chain Reaction; D015995:Prevalence; D012307:Risk Factors