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Is routine coronary angiography and revascularization indicated among patients undergoing evaluation for lung
Itsik Ben-Dor1, David Shitrit, Mordechai R Kramer
1Department of Cardiology, Rabin Medical Center, 39 Jabotinsky St, Petah Tikva, Israel 49100.
Insights
Coronary artery disease (CAD) is uncommon in lung transplant candidates and risk factors don't predict it well. Revascularization before lung transplantation may have complications and long delays, suggesting a more selective approach.
Area of Science:
- Cardiology
- Pulmonary Medicine
- Transplant Surgery
Background:
- Significant coronary artery disease (CAD) is a contraindication for lung transplantation (LTx).
- Coronary angiography (CA) is routinely advised for LTx candidates to screen for significant CAD.
Purpose of the Study:
- To determine the prevalence of CAD in lung transplantation candidates.
- To analyze the time interval between coronary angiography and lung transplantation or death.
- To evaluate outcomes after revascularization procedures in LTx candidates.
Main Methods:
- A retrospective review of lung transplantation candidates who underwent coronary angiography since 1997.
- Definition of significant CAD as stenosis greater than or equal to 70% diameter.
- Analysis of demographic and clinical data, revascularization outcomes, and survival post-LTx.
Main Results:
- Of 118 candidates over 40, significant CAD was found in 17.8%, nonsignificant CAD in 17.8%, and no CAD in 64.4%.
- Among those with significant CAD, 57.1% underwent successful percutaneous coronary intervention (PCI), but complications like infarction and stent thrombosis occurred.
- The median time from CA to LTx/death was 166 days, with no significant difference in outcomes based on CAD severity.
Conclusions:
- The prevalence of CAD among LTx candidates is low and not reliably predicted by risk factors.
- Revascularization may lead to complications and prolonged intervals before LTx.
- Routine coronary angiography and revascularization prior to LTx should be reconsidered, potentially reserved for high-risk patients.
Objectives:
To review coronary artery disease (CAD) prevalence among lung transplantation (LTx) candidates, the time interval from coronary angiography (CA) to LTx/death, and post-revascularization outcomes.
Background:
CA is advised for LTx candidates because significant CAD is a contraindication for LTx.
Methods:
We monitored all LTx candidates from 1997 who underwent CA. Significant CAD was defined as stenosis > or = 70% in diameter.
Results:
Of 118 candidates > 40 years old (68.3% men; median age, 58 years; 25 to 75th interquartiles, 53 to 61 years), 59 patients underwent LTx, 56 patients were eligible for LTx, and 3 patients were excluded due to CAD. Significant CAD was detected in 21 patients (17.8%), nonsignificant CAD was found in 21 patients (17.8%), and no CAD was found in 76 patients (64.4%), without significant differences in the demographic/clinical profile among patients with or without significant CAD. Among 21 patients with significant CAD, 12 patients (57.1%) underwent successful percutaneous coronary intervention (PCI), 1 patient had failed to respond to PCI, and 8 patients (38.1%) had no intervention. After PCI, one patient had periprocedural infarction, one patient had stent thrombosis, and one patient had symptomatic restenosis. The median time interval CA to LTx/death/last visit among the 115 candidates was 166 days (interquartiles, 48 to 410 days). Death occurred before LTx in 30 patients (53.5%) during a follow-up of 312 days (interquartiles, 46 to 664 days) and after LTx in 14 patients (23.7%) during a follow-up of 142 days (interquartiles, 73 to 304 days), without any difference in outcome based on severity of CAD in the two groups (p = 0.7 and p = 0.6, respectively).
Conclusions:
CAD prevalence among LTx candidates is low and cannot be accurately predicted by risk factors. Revascularization may be associated with complications, and the time interval between revascularization and LTx may be long. Conversely, certain patients with significant CAD underwent LTx without complications. The practice of routine CA and revascularization prior to LTx should be reconsidered, and perhaps reserved for selected patients with high-risk features.
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