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ISHLT Meeting in San Diego: A History of Science, Networking and Sun!

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Marco Masetti, MD, PhD
University of Bologna
Bologna, Italy

As usual, last ISHLT Meeting was full of new information and interesting sessions to be listened and actively participated, despite the interest for the sessions acutely conflicted with the pleasant weather of San Diego, and the sound of the ocean's waves clashed with the sound of science.

One novelty of this Meeting as compared with previous years was that Symposia were distributed among different days, thus potentially allowing an increased participation.

The great enthusiasm about mechanical circulatory support devices is growing, with the new device Heartmate III achieving interest in the overall scenario of MCS, given its particularly favorable profile regarding pump thrombosis. Dr Schmitto presented the results at 2-years of the CE Mark Trial, that confirmed high survival rates (74%), and no events of hemolysis, pump thrombosis or pump malfunction (identified by the new concept of hemocompatibility) with a rate of other adverse events per patient year comparable to the other devices actually available. Other interesting results were shown by the analysis of the ENDURANCE destination therapy trial, showing a comparable 2-year survival of patients in INTERMACS 1-2 vs 3-4 classes, but with patients in class 4 experiencing a higher rate of arrhythmias and bleeding.

Given the high number of transplanted patients with an LVAD, the attention focused also on the impact of MCS on pre-transplant allosensitization and on the waiting list and post-transplant outcomes. Particularly, in a great symposium session moderated by Andreas Zuckermann and Jon Kobashigawa it was shown that patients bridged to transplant with MCS can develop more frequently antibodies pre-transplant and early post-transplant, but their appearance doesn't seem to significantly affect post-transplant outcome: this concept supports the hypothesis that MCS-driven HLA antibodies may not represent the outcome of truly sensitizing events. In addition, MCS patients were not at a higher risk of developing de novo DSA late after HT.

However, Dr Patel showed that sensitized patients may experience longer waiting times, with higher mortality on the waiting list and a higher probability of delisting, while having an increased risk of rejection (although not affecting survival) after transplant. These considerations strongly underscore the importance of desensitization strategies pre-transplant. In Cedars Sinai experience, bortezomib associated with plasmapheresis appears to be effective in reducing alllosensitization and eculizumab may block complement-mediated injury induced by DSA, allowing successful transplantation with good outcomes and also highly sensitized candidates.

Primary graft dysfunction was another important issue addressed during symposia sessions. It was shown that ISHLT Classification for PGD can predict survival, having patients with severe PGD the lower 1-year survival rate; however, the usefulness of mild PGD vs no PGD in predicting prognosis is less certain. Another point of novelty was the actually recognized important role of post-operative vasoplegia (that can be more frequent in patients bridged with MCS) in determining PGD. Sometimes the two conditions are different to distinguish, with uncertainty to understand if they are the same rather than different entities.

The search for holy grail of non-invasive detection of rejection has been revived by the intriguing data of the donor-derived cell free DNA assay in predicting medium term outcomes; initial results from INTERHEART study suggests that a molecular-based approach may improve the diagnosis of rejection and can correlate with phenotypes of cardiac dysfunction.

Therefore, as discussed in the wonderful symposium "Let's Get Personal! Precision Diagnostics in Thoracic Transplantation," an individual assessment of rejection risk profile and monitoring through genetic and immunological assays seems to be the way to have in the future a "precision"-based personalized transplant medicine

Two symposia were dedicated to less known cardiomyopathies, like Chagas' cardiomyopathy and HIV-cardiomyopathy, and one symposium to pregnancy in transplanted women. The talks in these symposia started to abolish some historical barriers of the transplant community: the fear of transplanting an HIV+ patient, as well as of managing immunosuppression in a pregnant transplanted woman. However, these fears reflect also a lack of knowledge of these problems. Some of these diseases (like Chagas or HIV myocarditis) have a different prevalence around different parts of the world, between low and high income countries; the choice of the Symposium Committee of talk about them reflects the intention of ISHLT to be a real international society. Thus, it appears desirable also to have more involvement of international and young members from all parts of the world to enhance the intrinsic international mission of the Society.

Data from ISHLT Registry shows substantially stable outcomes after transplant, with older patients having low comorbidities and good, long term graft related outcomes comparable to young patients, due to their lower immunological reactivity; MCS increases the spectrum of candidates, allowing transplant in a formerly not eligible population without affecting post-transplant survival; patients with rare diseases can also be considered for transplant. Thus, the need for heart transplantation is continuously increasing, and we need to expand the availability of donors: in this sense, the results from the use of DCD donors are interesting. Dr Messer showed good results with 22 patients transplanted from DCD hearts: 5% in hospital mortality, suggesting that early outcomes of DCD hearts transplants are at least comparable with DBD counterparts.

Finally, beside real science, from a networking point of view, the Cheese and Wine Meetings of some scientific Councils, like Heart Failure and Heart Transplantation, and Junior Faculty and Trainee, were good occasions for people to better know each other and to share opinions and projects for the Society.

We are now waiting for the next Meeting in France (Nice) that could probably provide even better cheese and wine, hoping that it will also give even more science and international networking than the last successful Meeting in the beautiful San Diego. ■

Disclosure Statement: The author has no conflicts of interest to disclose.

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