Angiographic implications of cardiac transplantation

Coronary vascular disease in the cardiac transplant recipient has become the third most frequent cause of death or retransplantation after infection and acute rejection. A unique pattern of concentric fibrointimal thickening develops within 1 year of cardiac transplantation; however, it is relatively inapparent on routine arteriography. The disease progresses primarily in distal vasculature, leading to progressive occlusion. Angiographically discrete lesions associated microscopically with advanced atherosclerotic plaques frequently occur in the more proximal vessels often associated with thrombus. The number of rejection episodes is somewhat predictive of the development of transplant coronary disease. Annual arteriograms performed in cardiac transplant recipients have revealed several distinctive angiographic features that include clockwise rotation of the heart, presence of coronary arterial-cameral fistulae, presumably resulting from right ventricular endomyocardial biopsy specimens and collateralization of the brachial anastomosis from coronary atrial branches. It is concluded that serial angiography in cardiac transplant recipients is important in the early detection of progressive graft atherosclerosis, a process that is clinically silent until such time as overt heart failure or cardiogenic shock occurs.