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Published on: February 14, 2022
Surveillance for cardiac allograft vasculopathy: Practice variations among 50 pediatric heart transplant centers
Deipanjan Nandi1, Clifford Chin2, Kurt R Schumacher3
1Department of Pediatrics, Division of Cardiology, Nationwide Children's Hospital, Columbus, Ohio.
Insights
Coronary allograft vasculopathy (CAV) screening in children post-heart transplant shows routine angiography detects most cases, but symptom-based testing finds CAV more effectively. Developing risk models can optimize screening frequency.
Area of Science:
- Pediatric Cardiology
- Transplant Medicine
- Vascular Biology
Background:
- Coronary allograft vasculopathy (CAV) is a primary cause of death in pediatric heart transplant recipients.
- Variations in screening practices for CAV may influence detection rates and patient outcomes.
Purpose of the Study:
- To analyze the impact of different coronary evaluation strategies on CAV detection and patient outcomes in pediatric heart transplantation.
- To compare the effectiveness of routine versus symptom-based angiographic screening for CAV.
Main Methods:
- Retrospective analysis of 3,442 pediatric heart transplant recipients from 50 sites between 2001 and 2016.
- Coronary evaluations were categorized as routine or symptom-based angiography, with some sites supplementing with non-invasive tests.
- CAV detection rates, freedom from CAV, and mortality after CAV diagnosis were calculated and stratified by screening indication.
Main Results:
- CAV was detected in 14% of patients, with routine surveillance identifying the majority of cases (88%).
- Symptom-based angiograms had a higher CAV detection rate (29%) compared to routine angiograms (4%), though routine screening identified more overall cases.
- Five-year graft survival after CAV diagnosis was 58% overall, significantly lower for those diagnosed via symptom-based angiography (30%) versus routine angiography (62%).
Conclusions:
- Routine surveillance identifies most CAV cases, but symptom-based angiography is more sensitive for detection.
- Current screening practices vary, highlighting the need for optimized approaches.
- Developing risk-stratified models could enable less frequent invasive angiography for low-risk pediatric heart transplant patients without compromising outcomes.
Background:
Coronary allograft vasculopathy (CAV) is a leading cause of mortality after heart transplantation (HT) in children. Variation in CAV screening practices may impact detection rates and patient outcomes.
Methods:
Among 50 Pediatric Heart Transplant Society (PHTS) sites from 2001 to 2016, coronary evaluations were classified as angiography or non-invasive testing, and angiograms were designated as routine or symptom based. CAV detection rates stratified by routine vs symptom-based angiograms were calculated. Freedom from CAV and mortality after CAV diagnosis, stratified by study indication, were calculated.
Results:
A total of 3,442 children had 13,768 coronary evaluations; of these, 97% (n = 13,012) were for routine surveillance, and only 3% (n = 333) were for cause. Over the study period, CAV was detected in 472 patients (14%). Whereas 58% (n = 29) of PHTS sites evaluate by angiography alone, 42% reported supplementing with a non-invasive test, although only 423 non-invasive studies were reported. Angiographic detection of CAV was higher for symptom-based testing than for routine testing (29% vs 4%, p < 0.0001), although routine testing identified a majority of cases (88%; n = 414). The 10-year freedom from CAV was 77% overall. Once CAV is detected, 5-year graft survival was 58%, with lower survival for patients diagnosed after symptoms angiogram than after routine angiogram (30% vs 62%; p < 0.0001).
Conclusions:
Development of a robust model for CAV risk should allow low-risk patients to undergo less frequent invasive angiography without adverse impact on CAV detection rates or outcomes.
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