Therapeutic plasma exchange in patients with inflammatory dilated cardiomyopathy
Abstract
The aim of the study is to investigate the clinical efficiency of therapeutic plasma exchange (TPE) in patients with inflammatory dilated cardiomyopathy (iDCM) due to immune-mediated myocarditis in comparison with control group without TPE.
Material and methods. There were 19 iDCM patients in the treatment group (18 male, mean age 45.3±11.5 years, left ventricular end-diastolic diameter (LVEDD) 6.4±0.7 cm, left ventricular end- diastolic volume (LVEDV) 193.8±36.3 ml, left ventricular ejection fraction (LVEF) 34.6±6.9%, NYHA functional class II [II;III]) and 19 iDCM patients (12 male, mean age 46.3±12 years, LVEDD 6.6± 0.8 cm, LVEF 32.6±7.3%, NYHA functional class III [II;III]) who were followed without TPE. Treatment group patients underwent a single volume TPE filled with 0.9% sodium chloride (Sorvall RC 3BP+ Thermo scientific, Germany). All the patients had two or more fold increase of at least two anti-heart antibodies (AHA) level (to cardiac nuclear antigens, endothelial, cardiomyocytes, conduction and smooth muscle cells antigens) and underwent endomyocardial biopsy (EMB, n=13), cardiac CT (n=28), MRI (n=12), myocardial perfusion scan (n=15), and coronary angiography (n=13) to diagnose myocarditis. All the patients were treated either with immunosuppression drugs or without them. Echocardiographic parameters and AHA level detection were assessed at baseline and with two follow-up (FU) visits in about 6 and 12 month in both groups. We also evaluated a 6-minute walk test (6MWT) distance in the treatment group.
Results. AHA level significantly decreased just after TPE and during the FU in the treatment group (p<0.05). TPE group patients had significant improvement in LVEF (41.5±7.7% and 44.7±11.3% during the first and the second FU vs 39.1±13.7% and 37.2±10.7% in the control group, p<0.05). LVEDD, left and right atrial volume significantly decreased as well while they did not change during FU in the comparison group. TPE group patients had significant improvement in 6MWT distance during all the period. 12 (63%) TPE group patients with absolute LVEF improvement >10% were classified as responders vs 6 (32%) responders in the control group. Responders in TPE group were characterized by initial lower LVEF (35 [25;37]% vs 40 [37;43]% in non-responders, p<0.05) and larger right atrial volume (79 [70;100] ml vs 65 [40;71] ml in non-responders, p<0.05). ROC-curves showed right ventricular size more than 3.7 cm had 100% sensitivity and specificity in ability to identify good response to TPE. Initial LVED less than 38% showed 91.7% sensitivity and 71.4% specificity to predict good response to TPE. 9 (47.4%) TPE group patients and 17 (89.5%) control group patients got methylprednisolone (p<0.05). The mean dose was 8 [8;20] and 16 [13;28] mg per day respectively (p=0.075).
Conclusions. TPE improves cardiac function and daily activities in patients with iDCM. There were 63% TPE responders in treatment group. Initial right ventricular size more than 3.7 cm and LVED less than 38% was good outcome predictor of TPE efficiency. TPE helps avoid using immunosuppressive medications or reduce high doses of it.
Keywords:therapeutic plasma exchange, inflammatory dilated cardiomyopathy, myocarditis, immunosuppression drugs, anti-heart antibodies
For citation: Kulikova V.A., Nedostup A.V., Blagova O.V., Zaydenov V.A., Kupriyanova A.G., Nechaev I.A., Ragimov A.A. Therapeutic plasma exchange in patients with inflammatory dilated cardiomyopathy. Clin Experiment Surg. Petrovsky J. 2019; 7 (1): 6–16. doi: 10.24411/2308-1198-2019-11001. (in Russian)
Received 20.09.2018. Accepted 06.02.2019.
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