Cardiac transplantation followed by dose-intensive melphalan and autologous stem-cell transplantation for light chain amyloidosis and heart failure.
BACKGROUND
Patients with light chain (AL) amyloidosis who present with severe heart failure due to cardiac involvement rarely survive more than 6 months. Survival after cardiac transplantation is markedly reduced due to the progression of amyloidosis. Autologous stem-cell transplantation (ASCT) has become a common therapy for AL amyloidosis, but there is an exceedingly high treatment-related mortality in patients with heart failure.


METHODS
We developed a treatment strategy of cardiac transplant followed by ASCT. Twenty-six patients were evaluated, and of 18 eligible patients, nine patients underwent cardiac transplantation. Eight of these patients subsequently received an ASCT.


RESULTS
Six of seven evaluable patients achieved a complete hematologic remission, and one achieved a partial remission. At a median follow-up of 56 months from cardiac transplant, five of seven patients are alive without recurrent amyloidosis. Their survival is comparable with 17,389 patients who received heart transplants for nonamyloid heart disease: 64% in nonamyloid vs. 60% in amyloid patients at 7 years (P=0.83). Seven of eight transplanted patients have had no evidence of amyloid in their cardiac allograft.


CONCLUSIONS
This demonstrates that cardiac transplantation followed by ASCT is feasible in selected patients with AL amyloidosis and heart failure, and that such a strategy may lead to improved overall survival.
Dey
Bimalangshu R
BR
Massachusetts General Hospital, Boston, MA, USA.
Chung
Stephen S
SS
Spitzer
Thomas R
TR
Zheng
Hui
H
Macgillivray
Thomas E
TE
Seldin
David C
DC
McAfee
Steven
S
Ballen
Karen
K
Attar
Eyal
E
Wang
Thomas
T
Shin
Jordan
J
Newton-Cheh
Christopher
C
Moore
Stephanie
S
Sanchorawala
Vaishali
V
Skinner
Martha
M
Madsen
Joren C
JC
Semigran
Marc J
MJ
D000328:Adult; D000368:Aged; D000409:Alanine / Q000097:blood; D000686:Amyloidosis / Q000401:mortality / Q000601:surgery*; D001219:Aspartate Aminotransferases / Q000097:blood; D002316:Cardiotonic Agents / Q000627:therapeutic use; D005260:Female; D006333:Heart Failure / Q000601:surgery*; D016027:Heart Transplantation / Q000276:immunology*; D018380:Hematopoietic Stem Cell Transplantation / Q000379:methods*; D006801:Humans; D008297:Male; D008558:Melphalan / Q000627:therapeutic use*; D008875:Middle Aged; D033581:Stem Cell Transplantation / Q000379:methods*; D013318:Stroke Volume; D014182:Transplantation, Autologous
D002316:Cardiotonic Agents; D001219:Aspartate Aminotransferases; D000409:Alanine; D008558:Melphalan