Heart Transplantation and Chronic Lymphocytic Leukemia: A Successful Case at 2 Years of Follow-Up Nicola ´s Manito, MD, a Edgardo Kaplinsky, MD, a Josep Roca, MD, a Alberto Fernandez de Sevilla, MD, b Eduardo Castells, MD, PhD, a and Enrique Esplugas, MD, PhD c In June 2000, we successfully performed an orthotopic cardiac transplant in a 52-year-old man who, together with a B-cell chronic lymphocytic leukemia (Binet Stage A, Rai Stage 1), also had end-stage dilated idiopathic myocardiopathy. We describe his case and the 2 years of cancer-free follow-up. To our knowledge, this is the first report of a heart transplant in this setting. J Heart Lung Transplant 2004;23:777–9. Heart transplantation (HT) is the most effective therapy for patients with severe end-stage cardiac failure. 1 Historically, cancer antecedents were considered a contraindication for this procedure because of the theoretical risk associated with post-transplant immu- nosuppression. 2 Nevertheless, HT has been performed in adults and children who had been treated for malig- nancies, which suggests that carefully selected patients could expect a satisfactory survival with only a slight possibility of cancer recurrence. 3–5 In June 2000, we successfully performed an HT in a patient with chronic lymphocytic leukemia (CLL) who also had severe heart failure. CASE REPORT As a consequence of end-stage idiopathic heart disease, our 52-year-old male patient underwent an orthotopic HT in June 2000. The patient (left ventricular ejection fraction of 15%) had been hospitalized for 12 days before the procedure because of an acute decompen- sation. He received intravenous diuretics and progres- sive inotropic support. Previously (in October 1999), a B-cell CLL was diagnosed by chance when a complete blood count was performed during a routine examina- tion. The subject was accepted into our HT program because of his disease status: functional Class IV on the New York Heart Association (NYHA) scale and a low- to-intermediate grade of malignancy (Binet Stage A, Rai Stage 1). Pre-operative total leukocytes blood count was of 21,290/l (53% of them were small lymphocytes of ma- ture appearance). Analytical parameters of anemia and thrombocytopenia were not present. Physical examina- tion was normal. Computed tomography detected only a couple of small retroperitoneal lymphadenopathies, which were, in this context, linked to the malignancy. In this scenario, bone marrow examination was considered unnecessary and no specific treatment was indicated. 6 In June 2000, the patient underwent an orthotopic HT, receiving induction therapy with monoclonal anti- CD3 antibodies (OKT3; 7 doses of 2.5 mg each) and an intraoperative bolus of methylprednisolone (500 mg). Immunosuppression was done with cyclosporine, my- cophenolate mofetil and prednisone. Dosage of cyclo- sporine was sufficient to maintain blood concentrations of between 150 to 300 ng/ml (measured by radioimmu- noassay), mycophenolate mofetil was administered orally (1 g twice daily) and methylprednisolone was initiated at 0.5 mg/kg for 6 days. Subsequently, pred- nisone was administered at 1 mg/kg and then tapered to 0.3 mg/kg by the end of the first month and to about 0.1 mg/kg by the end of the first year. Since the operation he has not required any hospital- ization and no infections have been documented. Two additional computed tomography scans (1 each year) were obtained and no disease progression was ob- served. No further bone marrow analyses were per- formed during the course of observation. A surveillance endomyocardial biopsy was performed 102 days after the transplantation, which revealed Grade 3A cellular rejection (ISHLT). This was satisfactorily treated follow- ing our institution’s specific schema (in the absence of hemodynamic compromise) with an oral pulse of pred- nisone (50 mg/day for 3 days) and an increase of immunosuppression (cyclosporine and mycophenolate mofetil) (Table 1). The time elapsed between cancer diagnosis and transplantation was about 9 months and the explanted heart revealed only features of an idiopathic disease (Figure 1). From the a Heart Transplant Unit, b Hematology Unit and c Cardiology Unit, Bellvitge Hospital, University of Barcelona, Barcelona, Spain. Submitted December 11, 2002; revised June 25, 2003; accepted July 2, 2003. Reprint requests: Nicola ´s Manito, MD, Heart Transplant Unit, Hospital Universitari Bellvitge, Feixa Llarga s/n, 08907 L’Hospitalet del Llobregat, Barcelona, Spain. Telephone: +34-93-260-79-31. Fax: +34-93-260-76-19. E-mail: nml@csub.scs.es Copyright © 2004 by the International Society for Heart and Lung Transplantation. 1053-2498/04/$–see front matter. doi:10.1016/ j.healun.2003.07.013 777