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Long-term mortality after cardiac allograft vasculopathy: implications of percutaneous intervention
Shikhar Agarwal1, Akhil Parashar1, Samir R Kapadia1
1Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Insights
Percutaneous intervention (PCI) improves long-term survival for heart transplant recipients with cardiac allograft vasculopathy (CAV). Patients with severe CAV unsuitable for PCI face higher mortality risks, highlighting the benefit of timely intervention.
Area of Science:
- Cardiology
- Transplant Medicine
- Immunology
Background:
- Cardiac allograft vasculopathy (CAV) is a leading cause of graft failure after orthotopic heart transplantation (OHT).
- The effectiveness of percutaneous intervention (PCI) for treating focal CAV remains incompletely understood.
- Progressive arterial narrowing in CAV significantly impacts long-term outcomes in OHT recipients.
Purpose of the Study:
- To compare the long-term prognosis of patients with proximal cardiac allograft vasculopathy (CAV) treated with percutaneous intervention (PCI).
- To evaluate the outcomes of severe CAV cases not amenable to PCI.
- To assess the impact of CAV severity on long-term mortality after OHT.
Main Methods:
- Retrospective analysis of 393 patients with moderate to severe CAV undergoing OHT at Cleveland Clinic.
- Coronary angiograms were reviewed and graded using ISHLT nomenclature.
- Comparison of survival rates between patients treated with PCI and those with severe CAV unsuitable for intervention.
Main Results:
- Worsening CAV severity correlated with increased long-term mortality, with ISHLT grade 3 exhibiting the highest mortality.
- PCI was associated with significantly reduced mortality risk at 2- and 5-year follow-ups compared to severe CAV not amenable to PCI.
- Statin use demonstrated a significant survival benefit in patients with CAV.
Conclusions:
- Progressive CAV severity is linked to worse long-term survival in heart transplant recipients.
- Patients with CAV amenable to PCI have better long-term survival than those with severe CAV not treatable with PCI.
- PCI offers a survival advantage for selected OHT recipients with CAV.
Objectives:
This study compared the prognosis of patients with proximal cardiac allograft vasculopathy (CAV) treated with percutaneous intervention (PCI) to the prognosis of those with severe CAV not amenable to PCI.
Background:
CAV is a progressive form of arterial narrowing affecting patients with orthotopic heart transplants (OHTs). PCI has been used to treat patients with focal CAV, but its efficacy remains unclear.
Methods:
Of 853 patients undergoing OHT and subsequent coronary angiographies at the Cleveland Clinic, all patients with at least moderate CAV (>30%) on any coronary angiogram following OHT were included. Of remaining patients with no/mild CAV, 200 patients were randomly chosen to represent the comparison group. All angiograms of the included patients were reviewed and graded according to the International Society of Heart and Lung Transplantation (ISHLT) nomenclature.
Results:
Of the 393 included patients, 100 patients underwent definitive intervention for CAV. Of these 100 patients, 90 patients underwent PCI only, 6 patients underwent coronary artery bypass grafting, and 4 patients underwent repeat OHT. We observed a progressive increase in long-term mortality with worsening CAV. Patients with ISHLT grade 3 CAV had the highest long-term mortality compared with other groups. In addition, there was a significant reduction in the risk for mortality at 2-year follow-up (adjusted odds ratio: 0.26; 95% confidence interval [CI]: 0.08 to 0.82) and 5-year follow-up (adjusted odds ratio: 0.28; 95% CI: 0.09 to 0.93) after PCI compared with patients diagnosed with ISHLT grade 3 CAV, who were deemed unsuitable for PCI. Furthermore, statin use was associated with a significant survival benefit in patients with CAV (hazard ratio: 0.21; 95% CI: 0.07 to 0.61).
Conclusions:
Worsening severity of CAV was associated with progressively worse long-term survival among heart transplant recipients. Among patients with CAV, long-term survival in those with CAV amenable to PCI was greater than that in those with severe CAV not treatable with PCI.
