Percutaneous coronary interventions and bypass surgery in patients with cardiac allograft vasculopathy: a
O Prada-Delgado1, R Estévez-Loureiro, A López-Sainz
1Transplant and Advanced Heart Failure Unit, Division of Cardiology, Complejo Hospitalario Universitario A Coruña, Spain. Oscar.Prada.Delgado@sergas.es
Insights
Coronary revascularization benefits heart transplant recipients with symptomatic or high-risk cardiac allograft vasculopathy (CAV). Patients without ischemia show good prognosis, while diffuse nonrevascularizable CAV indicates a poor outlook.
Area of Science:
- Cardiology
- Transplantation Medicine
- Vascular Biology
Background:
- Cardiac allograft vasculopathy (CAV) significantly impacts long-term survival post-heart transplantation (HT).
- Limited data exist on the efficacy of coronary revascularization in managing CAV.
- Understanding CAV progression and treatment is crucial for improving outcomes in HT patients.
Purpose of the Study:
- To assess the outcomes of revascularization in heart transplant recipients with CAV.
- To compare outcomes between revascularized and non-revascularized CAV patients.
- To identify prognostic factors in CAV management.
Main Methods:
- Retrospective analysis of 249 heart transplant recipients undergoing coronary angiography.
- Inclusion of patients with moderate to severe CAV based on ISHLT nomenclature.
- Evaluation of major adverse cardiovascular events (MACE) after revascularization or diagnostic angiography.
Main Results:
- Moderate or severe CAV was identified in 43 patients; 12 underwent revascularization (PCI or bypass).
- Revascularization indications included symptomatic/high-risk CAV (ischemia, specific lesion locations, or LV dysfunction).
- MACE occurred in 25% of revascularized patients versus 65% with nonrevascularizable disease (P=.012).
Conclusions:
- Coronary revascularization is effective for heart transplant recipients with ischemic or high-risk CAV.
- Absence of stress-induced ischemia predicts a good prognosis without revascularization.
- Diffuse, nonrevascularizable CAV is associated with a significantly poorer prognosis.
Introduction:
Cardiac allograft vasculopathy (CAV) remains a major impediment to long-term survival after heart transplantation (HT). Limited data exist regarding the impact of coronary revascularization in these patients.
Objective:
To evaluate the outcomes of revascularization procedures in patients with CAV compared with patients who did not undergo revascularization.
Methods:
Retrospective analysis of 249 patients who underwent HT at our center between June 1998 and December 2009 and who were examined by coronary angiography after HT. We included patients with moderate or severe CAV according to the International Society for Heart and Lung Transplantation (ISHLT) nomenclature to evaluated outcomes after revascularization or diagnostic angiography. Major adverse cardiovascular events (MACE) comprised death, acute coronary syndrome, coronary revascularization, admission because of heart failure not due to an acute rejection episode, and cardiac retransplantation.
Results:
Moderate or severe CAV was detected in 43 patients. Twelve (27.9%) underwent coronary revascularization: eight percutaneous interventions and four bypass surgeries. Indications for revascularization were symptomatic ischemia or noninvasive evidence of ischemia (n = 6, 14.0%) or high-risk asymptomatic CAV (n = 6; 14.0%), namely, lesions located in the left main or proximal anterior descending arteries or multivessel disease with left ventricular dysfunction. The remaining 31 (72.1%), who did not undergo revascularization showed an absence of ischemia during exercise echocardiography (n = 11; 25.6%) or diffuse disease not amenable to revascularization (n = 20; 46.5%). During a mean follow-up of 3.0 ± 2.4 years, MACE occurred in three revascularized patients (25.0%), in one with absence of stress-induced ischemia (9.1%) and in 13 with nonrevascularizable disease (65%; P = .012).
Conclusions:
Revascularization procedures were effective in HT patients with evidence of ischemia or high-risk CAV. Patients with absence of stress-induced ischemia have a good prognosis without revascularization. On the other hand, diffuse nonrevascularizable CAV is associated with a poor prognosis.
