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Coronary angiography after heart transplantation: should perioperative study be the "gold standard"?
Insights
Early diagnosis of allograft coronary arteriopathy is crucial. Coronary angiography is optimal for detection, with initial studies recommended within 8 weeks post-transplant to assess donor heart abnormalities.
Area of Science:
- Cardiology
- Transplantation Immunology
Background:
- Allograft coronary arteriopathy is common and has a poor prognosis, necessitating early diagnosis.
- Standard noninvasive tests have limited sensitivity and specificity for allograft arteriopathy due to differences from native coronary artery disease.
Purpose of the Study:
- To establish the optimal timing for initial coronary angiography after heart transplantation.
- To determine the incidence of coronary artery abnormalities in donor hearts.
- To evaluate the utility of serial quantitative angiography in detecting disease progression.
Main Methods:
- Review of perioperative coronary angiograms in 75 heart transplant recipients (within 8 weeks).
- Serial quantitative angiography (baseline and 12-month follow-up) of the left anterior descending artery in 28 patients.
- Visual assessment of angiograms for allograft arteriopathy.
Main Results:
- Only 6 out of 75 donor hearts showed abnormalities on initial perioperative angiograms (within 8 weeks).
- No significant luminal diameter reduction was observed in serial quantitative angiography over 12 months.
- Visual assessment detected allograft arteriopathy in 7 of 28 patients despite no significant diameter changes.
Conclusions:
- Initial coronary angiography within 8 weeks of heart transplantation reveals a low incidence of donor heart coronary abnormalities.
- Serial quantitative angiography may not be sensitive enough to detect early allograft arteriopathy.
- Visual inspection of serial angiograms can identify allograft arteriopathy even without significant diameter reduction.
Abstract:
The fact that allograft coronary arteriopathy is frequent and has a poor prognosis means early diagnosis is critical. Furthermore, because of important distinctions between native heart coronary artery disease and allograft arteriopathy, standard noninvasive diagnostic tests seem less sensitive and specific. Assuming that coronary angiography is the optimal method for detection and staging of allograft arteriopathy, one must establish the point at which an initial study should be performed and the incidence of abnormalities in donor hearts. Review of perioperative coronary angiograms in 75 consecutive patients undergoing heart transplantation (within 8 weeks) demonstrated that only six hearts had coronary artery abnormalities: two had focal coronary artery disease, one had an anomalous circumflex coronary artery, and three had nonobstructive calcification of the coronary arteries. To determine if serial quantitative angiography was helpful in detecting progression of coronary disease during a 12-month period, 28 patients underwent baseline and repeat quantification of mean luminal diameter of predetermined segments of the mid and distal portions of the left anterior descending artery. No patient had identifiable disease on the first angiogram, and 12 were studied in the first year of their transplants. During the interval, mean mid left anterior descending coronary diameter was 3.17 +/- 0.6 mm on the first study and 3.06 +/- 0.7 on the second study. Visual assessment of the angiograms, however, identified allograft arteriopathy when two studies were available for inspection in 7 of 28 patients despite no significant diameter reduction of identified coronary segments.(ABSTRACT TRUNCATED AT 250 WORDS)