Abstract
Background: Cardiac allograft vasculopathy (CAV), a form of accelerated atherosclerosis, is the major cause of late death in heart transplant recipients. Routine annual coronary angiography has been used as the standard surveillance technique for CAV in most transplant centers.
Hypothesis: The aim of this study was to investigate the clinical utility of routine angiographic surveillance in the detection and management of CAV in transplant recipients.
Methods: We reviewed the case notes and angiograms of 230 patients who underwent cardiac transplantation in our unit between January 1986 and January 1996 and survived beyond the first year post transplantation.
Results: Significant complications secondary to angiography arose in 19 patients (8.2%). Cardiac allograft vasculopathy was present on none of angiograms performed 3 weeks post transplantation, but was identified in 9 patients (4%) at the first annual angiogram and an additional 25 patients by the fifth annual angiogram. A target lesion suitable for angioplasty was only identified in two patients, and only limited procedural success was achieved in both cases. Twenty‐five patients (11%) died during the study period, and the most common cause of late death was graft failure which occurred in 10 patients. All patients who died from graft failure had significant CAV at autopsy, but the most recent coronary angiogram had been normal in eight of these patients.
Conclusions: These data clearly illustrate the limited clinical utility of routine angiographic surveillance for CAV in heart transplant recipients and prompted us to abandon this method of surveillance in our unit.
Keywords: cardiac allograft vasculopathy, angiography, surveillance
Full Text
The Full Text of this article is available as a PDF (454.4 KB).
References
- 1. Weiss M, von Scheidt W: Cardiac allograft vasculopathy: A review. Circulation 1997; 96: 2069–2077 [DOI] [PubMed] [Google Scholar]
- 2. Hosenpud JD, Everett JP, Morris TE, Mauck KA, Shipley GD, Wagner CR: Cardiac allograft vasculopathy. Circulation 1995; 92: 205–211 [DOI] [PubMed] [Google Scholar]
- 3. Mangiavacchi M, Frigerio M, Gronda E, Danzi GB, Bonacina E, Masciocco G, Olivia F, De Vita C, Pellegrini A: Acute rejection and cytomegalovirus infection: Correlation with cardiac allograft vasculopathy. Transplant Proc 1995; 27: 1960–1962 [PubMed] [Google Scholar]
- 4. Dressler FA, Miller LW: Necropsy versus angiography: How accurate is angiography?. J Heart Lung Transplant 1992; 11: 56–59 [PubMed] [Google Scholar]
- 5. Miller LW: Role of intracoronary ultrasound for the diagnosis of cardiac allograft vasculopathy. Transplant Proc 1995; 27: 1989–1992 [PubMed] [Google Scholar]
- 6. Billingham ME: Diagnosis of cardiac rejection by endocardial biopsy. J Heart Lung Transplant 1981; 1: 25–30 [Google Scholar]
- 7. Valantine H, Pinto FJ, St. Goar GF, Alderman EL, Popp RL: Intracoronary ultrasound imaging in heart transplant recipients: The Stanford experience. J Heart Lung Transplant 1992; 11: 60–64 [PubMed] [Google Scholar]
- 8. Billingham ME: Histopathology of graft coronary artery disease. J Heart Lung Transplant 1992; 3: 538–544 [PubMed] [Google Scholar]
- 9. McGiffin DC, Sauvenen T, Kirklin JK, Naftel DC, Bourge RC, Paine TD, White‐Williams C, Sisto T, Early L: Cardiac transplant coronary artery disease. A multivariable analysis of pretransplantation risk factors for disease development and morbid events. J Thorac Cardiovasc Surg 1995; 109: 1081–1089 [DOI] [PubMed] [Google Scholar]
- 10. Gao S, Alderman EL, Schroeder JS, Hunt SA, Wiederhold V, Stinson EB: Progressive coronary lumenal narrowing after cardiac transplantation. Circulation 1990; 82: 269–275 [PubMed] [Google Scholar]
- 11. Pascoe EA, Barnhart GR, Carter WH Jr, Thompson JA, Hess ML, Hastillo A, Szentpetery S, Lower RR: The prevalence of cardiac allograft arteriosclerosis. Transplantation 1987; 44: 838–839 [DOI] [PubMed] [Google Scholar]
- 12. Keogh A, MacDonald P, Harrison A, Richens D, Mundy J, Spratt P: Initial steroid free versus steroid based maintenance therapy and steroid withdrawal after heart transplantation: Two views of the steroid question. J Heart Lung Transplant 1992; 11: 421–427 [PubMed] [Google Scholar]
- 13. Pethig K, Heublein B, Wahlers T: Impact of plaque burden on compensatory enlargement of coronary arteries in cardiac allograft vasculopathy. Working group on cardiac allograft vasculopathy. Am J Cardiol 1997; 79: 89–92 [DOI] [PubMed] [Google Scholar]
- 14. Hausmann D, Erbel R, Alibelli‐Chemarin MJ, Boksch W, Caracciolo E, Cohn JM, Culp SC, Daniel WG, De Scheerder I, DiMario C, Ferguson JJ III, Fitzgerald PJ, Friedrich G, Ge J, Görge G, Hanrath P, Hodgson JM, Isner JM, Jain S, Maier‐Rudolph W, Mooney M, Moses JW, Mudra H, Pinto FJ, Smalling RW, Talley JD, Tobis JM, Walter PD, Weidinger F, Werner GS, Yeung AC, Yock PG: The safety of intracoronary ultrasound: A multicenter survey of 2,207 examinations. Circulation 1995; 91: 623–630 [DOI] [PubMed] [Google Scholar]
- 15. Smart FW, Ballantyne CM, Cocanough B, Farmer JA, Sekela ME, Noon GP, Young JB: Insensitivity of non‐invasive tests to detect coronary artery vasculopathy after heart transplantation. Am J Cardiol 1991; 67: 243–247 [DOI] [PubMed] [Google Scholar]
- 16. Spes CH, Mudra H, Schnaack SD, Tammen AR, Rieber J, Uberfuhr P, Reichart B, Theisen K, Angermann CE: Role of dobutamine stress echocardiography for diagnosis of cardiac allograft vasculopathy. Transplant Proc 1998; 30: 904–906 [DOI] [PubMed] [Google Scholar]
- 17. Halle AA III, DiSciascio G, Massin EK, Wilson RF, Johnson MR, Sullivan HJ, Bourge RC, Kleiman NS, Miller LW, Aversano TR, Wray RB, Hunt SA, Weston MW, Davies RA, Rincon G, Crandall CC, Cowley MJ, Fisher SG, Vetrovec GW: Coronary angioplasty, atherectomy and bypass surgery in cardiac transplant recipients. J Am Coll Cardiol 1995; 26: 120–128 [DOI] [PubMed] [Google Scholar]
- 18. March RJ, Guynn T: Cardiac allograft vasculopathy: Potential role for transmyocardial laser revascularisation. J Heart Lung Transplant 1995; 14: S242–S246 [PubMed] [Google Scholar]