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Coronary occlusive disease and late graft failure after cardiac transplantation
P A Mullins1, N R Cary, L Sharples
1Transplant Unit, Papworth Hospital, Huntingdon, Cambridge.
Insights
Coronary occlusive disease is a major cause of graft failure after cardiac transplantation. This study found it involves thrombosis, stenoses, and cardiomegaly, impacting long-term survival.
Area of Science:
- Cardiology
- Transplantation Medicine
- Pathology
Background:
- Coronary occlusive disease (COD) is a primary cause of late mortality following cardiac transplantation.
- The pathophysiology of graft failure due to COD remains incompletely understood.
- This study reviews the experience with COD in a cardiac transplant program.
Purpose of the Study:
- To investigate the characteristics and impact of coronary occlusive disease in cardiac transplant recipients.
- To elucidate the contributing factors to late graft failure from COD.
Main Methods:
- Retrospective analysis of angiographic and pathological data from cardiac transplant recipients.
- Review of 447 coronary angiograms from 193 patients and 13 post-mortem examinations.
Main Results:
- Angiographic prevalence of COD reached 40% by five years post-transplant.
- COD accounted for 26 graft failures; acute thrombosis was seen in 54% of fatal cases.
- Cardiomegaly was present in 92% of patients with fatal COD.
Conclusions:
- Coronary occlusive disease is the principal late complication after cardiac transplantation.
- Graft failure is attributed to a combination of coronary thrombosis, large and small vessel stenoses, and cardiomegaly.
Objective:
Coronary occlusive disease is the main cause of late mortality after cardiac transplantation. It has both similarities and differences compared with conventional atherosclerotic coronary disease. The pathophysiology of late graft failure from coronary occlusive disease is unclear at present. We reviewed the experience of this disorder in our cardiac transplant programme.
Design:
A retrospective analysis of angiographic and pathological data.
Setting:
A regional cardiothoracic centre and transplant unit.
Patients:
Of a population of 383 orthotopic cardiac transplant recipients operated upon between January 1979 and June 1990, 447 coronary angiograms were available for review in 193 patients. Thirteen of a possible 18 results of post mortem examinations from patients dying from coronary occlusive disease were available.
Main Outcome Measure:
Coronary occlusive disease was defined as any evidence of disease on coronary angiography. Post mortem examinations were performed with standard techniques.
Results:
The angiographic prevalence of coronary occlusive disease was 3% (1/32 patients) and 40% (19/47 patients) at one and five years respectively. Twenty six grafts failed due to coronary occlusive disease compared with 132 graft failures from all causes during this period. Acute thrombosis was present in a large vessel in seven of 13 fatal cases undergoing necropsy (54%). Noticeable large vessel involvement with disease in smaller distal vessels was present in four patients (31%). The remaining two patients (15%) had small vessel disease alone. Twelve of the 13 patients had significant cardiomegaly (cardiac weight > or = 400 g) with a mean weight of 510 (range 370-740) g.
Conclusion:
Coronary occlusive disease is the main late complication after cardiac transplantation. A combination of coronary thrombosis, ischaemia from stenoses of large and small coronary vessels, and cardiomegaly contribute to the graft failure of these patients.