title: Management of immunosuppression and antiviral treatment before and after heart transplant for HIV-associated dilated cardiomyopathy.
abstract: Infection with HIV may lead to the development of cardiomyopathy as improved antiretroviral regimens continue to prolong patient life. However, advanced therapeutic options, such as heart transplant, have until recently been precluded to HIV-positive persons. A favorable long-term outcome has been obtained after kidney or liver transplant in HIV-positive recipients fulfilling strict virological and clinical criteria. We recently reported the first heart transplant in a HIV-infected patient carried out in our center. In this article, we detail the major challenges we faced with the management of antiretroviral and immunosuppressive treatments over the first 3 years post-transplant. The patient had developed dilated cardiomyopathy while on antiretroviral treatment with zidovudine, lamivudine and efavirenz. He was in WHO Stage 1 of HIV infection and had normal CD4+ count and persistently undetectable HIV-RNA. In spite of cardiac resynchronization therapy and maximal drug therapy, the patient progressed to end stage heart failure, requiring heart transplant. He was placed on a standard immune suppressive protocol including cyclosporine A and everolimus. Despite its potential pharmacokinetic interaction with efavirenz, everolimus was chosen to reduce the long-term risk of opportunistic neoplasia. Plasma levels of both drugs were monitored and remained within the target range, although high doses of everolimus were needed. There were no infectious, neoplastic or metabolic complications during a 3-year follow-up. In summary, our experience supports previous data showing that cardiac transplantation should not be denied to carefully selected HIV patients. Careful management of drug interactions and adverse events is mandatory.
authors.affiliation: Divisions of Internal Medicine, Department of Cardiothoracic Sciences, 2nd University of Naples Medical School and V. Monaldi Hospital, Naples, Italy.
authors.forename: E
authors.initials: E
authors.lastname: Durante-Mangoni
authors.affiliation: Cardiac Surgery, Department of Cardiothoracic Sciences, 2nd University of Naples Medical School and V. Monaldi Hospital, Naples, Italy.
authors.forename: C
authors.initials: C
authors.lastname: Maiello
authors.affiliation: Cardiology, Department of Cardiothoracic Sciences, 2nd University of Naples Medical School and V. Monaldi Hospital, Naples, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Limongelli
authors.affiliation: Division of Infectious and Immunological Diseases, D. Cotugno Hospital, Naples, Italy.
authors.forename: C
authors.initials: C
authors.lastname: Sbreglia
authors.affiliation: Divisions of Internal Medicine, Department of Cardiothoracic Sciences, 2nd University of Naples Medical School and V. Monaldi Hospital, Naples, Italy.
authors.forename: D
authors.initials: D
authors.lastname: Pinto
authors.affiliation: Cardiac Surgery, Department of Cardiothoracic Sciences, 2nd University of Naples Medical School and V. Monaldi Hospital, Naples, Italy.
authors.forename: C
authors.initials: C
authors.lastname: Amarelli
authors.affiliation: Cardiology, Department of Cardiothoracic Sciences, 2nd University of Naples Medical School and V. Monaldi Hospital, Naples, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Pacileo
authors.affiliation: Division of Infectious and Immunological Diseases, D. Cotugno Hospital, Naples, Italy.
authors.forename: A
authors.initials: A
authors.lastname: Perrella
authors.affiliation: Divisions of Internal Medicine, Department of Cardiothoracic Sciences, 2nd University of Naples Medical School and V. Monaldi Hospital, Naples, Italy.
authors.forename: F
authors.initials: F
authors.lastname: Agrusta
authors.affiliation: Cardiac Surgery, Department of Cardiothoracic Sciences, 2nd University of Naples Medical School and V. Monaldi Hospital, Naples, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Romano
authors.affiliation: Cardiac Surgery, Department of Cardiothoracic Sciences, 2nd University of Naples Medical School and V. Monaldi Hospital, Naples, Italy.
authors.forename: C
authors.initials: C
authors.lastname: Marra
authors.affiliation: Department of Infectious Diseases, Catholic University of the Sacred Heart, Rome, Italy.
authors.forename: S
authors.initials: S
authors.lastname: Di Giambenedetto
authors.affiliation: Cardiac Surgery, Department of Cardiothoracic Sciences, 2nd University of Naples Medical School and V. Monaldi Hospital, Naples, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Nappi
authors.affiliation: Divisions of Internal Medicine, Department of Cardiothoracic Sciences, 2nd University of Naples Medical School and V. Monaldi Hospital, Naples, Italy.
authors.forename: R
authors.initials: R
authors.lastname: Utili
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000493:pharmacokinetics / Q000627:therapeutic use*; D002311:Cardiomyopathy, Dilated / Q000188:drug therapy / Q000209:etiology / Q000601:surgery* / Q000821:virology; D004347:Drug Interactions; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy* / Q000276:immunology / Q000601:surgery; D016027:Heart Transplantation; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000493:pharmacokinetics / Q000627:therapeutic use*; D008297:Male; D016896:Treatment Outcome
chemical_list: D019380:Anti-HIV Agents; D007166:Immunosuppressive Agents