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Percutaneous coronary intervention versus medical therapy for coronary allograft vasculopathy. One center's
Juan M Aranda1, Daniel F Pauly, Richard A Kerensky
1Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, USA. arandjm@mail-cs.med.ufl.edu
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Percutaneous coronary intervention (PCI) did not improve survival for heart transplant recipients with coronary allograft vasculopathy compared to aggressive medical therapy alone. Outcomes were similar between PCI and medical therapy groups in this study.
Area of Science:
- Cardiology
- Transplantation Medicine
- Vascular Biology
Background:
- Coronary allograft vasculopathy (CAV) is a major limitation to long-term survival after heart transplantation.
- Aggressive medical therapy and percutaneous coronary intervention (PCI) are used to manage CAV, but long-term outcome data are limited.
Purpose of the Study:
- To compare clinical outcomes of heart transplant recipients with CAV treated with PCI versus aggressive medical therapy alone.
Main Methods:
- Retrospective analysis of 79 heart transplant recipients diagnosed with CAV between 1995 and 2000.
- Patients were stratified into aggressive medical therapy or PCI groups.
- Clinical outcomes, including survival, were analyzed.
Main Results:
- Patients receiving PCI were older at baseline than those receiving medical therapy.
- Mortality was higher in patients with CAV compared to those without.
- No significant difference in 1-year or 3-year survival was observed between the PCI and medical therapy groups.
Conclusions:
- Heart transplant recipients with CAV have reduced survival rates.
- Percutaneous coronary intervention (PCI) does not offer a survival advantage over aggressive medical therapy alone for patients with CAV.
Background:
Coronary allograft vasculopathy, a rapidly progressive form of atherosclerosis, remains the limiting factor in the long-term survival of heart transplant recipients. Some centers have attempted percutaneous coronary intervention to slow the disease process and thereby reduce mortality in these patients, but long-term follow-up data are scarce. We compared clinical outcomes in heart transplant recipients with coronary allograft vasculopathy who were treated either with percutaneous coronary intervention or with aggressive medical therapy alone.
Methods:
A retrospective analysis of all heart transplant recipients at our institution who underwent surveillance coronary angiography for coronary allograft vasculopathy between 1995 and 2000 was performed. Patients with coronary allograft vasculopathy were stratified according to whether they received medical therapy or percutaneous coronary intervention. Baseline demographics, results of re-vascularization procedures and outcomes were analyzed.
Results:
From 1995 to 2000, 301 patients underwent 602 coronary angiograms. Of the 79 patients who had angiographic evidence of coronary allograft vasculopathy, 53 were treated with aggressive medical therapy, while 26 underwent percutaneous coronary intervention in addition to aggressive medical therapy. At baseline, patients treated with aggressive medical therapy tended to be younger (54.6 +/- 13.8 years) than patients treated with percutaneous coronary intervention (62.6 +/- 7.6 years; p = 0.0079). Ejection fraction at time of diagnosis of coronary allograft vasculopathy was similar for both groups (medical therapy group, 44.4 +/- 13.4% vs percutaneous coronary intervention group, 47.2 +/- 12.7%; p = 0.38). In our cohort, heart transplant recipients with coronary allograft vasculopathy demonstrated greater mortality than heart transplant recipients without coronary allograft vasculopathy (p = 0.016). Patients who underwent percutaneous coronary intervention had a 60% re-stenosis rate at 6 months if they were treated with coronary angioplasty and an 18% re-stenosis rate if they received a coronary stent. Kaplan-Meier analysis showed no significant difference in survival in either treatment group at 1 year (80% for medical therapy group vs 95% for percutaneous coronary intervention group) or 3 years (68% for medical therapy group vs 79% for percutaneous coronary intervention group) after the angiographic diagnosis of coronary allograft vasculopathy.
Conclusion:
In this non-randomized trial, heart transplant recipients with coronary allograft vasculopathy were less likely to survive than patients without it. In addition, we found no statistical difference in mortality in heart transplant recipients with coronary allograft vasculopathy, regardless of whether they received percutaneous coronary intervention or aggressive medical therapy alone.