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Published on: August 2, 2024
Influence of Donor Transmitted and Rapidly Progressive Coronary Vascular Disease on Long-Term Outcomes After Heart
Brett W Sperry1, Raed Qarajeh2, Mohamed A Omer2
1Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.
Insights
Donor-transmitted atherosclerosis (DTA) and rapidly progressive cardiac allograft vasculopathy (CAV) do not predict adverse outcomes in current heart transplant patients. Further research should focus on other factors like rejection for predicting poor prognosis.
Area of Science:
- Cardiology
- Transplantation Medicine
- Medical Imaging
Background:
- Donor-transmitted atherosclerosis (DTA) and rapidly progressive cardiac allograft vasculopathy (CAV) are intravascular ultrasound (IVUS)-derived measures.
- These measures previously predicted adverse cardiovascular outcomes with early immunosuppressive agents.
- Current data on IVUS prognostic value in contemporary heart transplantation is limited.
Purpose of the Study:
- To investigate the association of IVUS-derived DTA and rapidly progressive CAV with adverse outcomes in modern heart transplant recipients.
- To explore the prognostic value of these IVUS measurements in the current era of immunosuppression.
Main Methods:
- Retrospective cohort analysis of 249 heart transplant patients (2009-2016) with baseline and 1-year IVUS.
- IVUS analyzed for intimal thickness and lumen area; DTA defined as >=0.5 mm intimal thickness at baseline.
- Rapidly progressive CAV defined as >=0.5 mm increase in intimal thickness at 1 year.
Main Results:
- DTA detected in 51.4% of patients; rapidly progressive CAV assessed at 1 year.
- Median follow-up of 6.1 years; 45 patients (18.1%) met the primary composite endpoint.
- DTA and rapidly progressive CAV were not associated with the primary endpoint, mortality, or retransplantation.
Conclusions:
- In a contemporary heart transplant cohort, IVUS-derived DTA and rapidly progressive CAV lack prognostic value for medium- to long-term adverse events.
- Incident rejection, however, was strongly associated with poor outcomes.
- Cytomegalovirus infection did not show a significant association with adverse outcomes.
Background:
Donor-transmitted atherosclerosis (DTA) and rapidly progressive cardiac allograft vasculopathy (CAV) at 1 year are intravascular ultrasound (IVUS)-derived measures shown to predict adverse cardiovascular outcomes in the setting of early generation immunosuppressive agents. Given the paucity of data on the prognostic value of IVUS-derived measurements in the current era, we sought to explore their association with adverse outcomes after heart transplantation.
Methods And Results:
This is a retrospective cohort analysis of patients who underwent heart transplantation at our center between January 2009 and June 2016 with baseline and 1-year IVUS. Five IVUS sections were prospectively analyzed for intimal thickness and lumen area. DTA was defined as maximum intimal thickness of 0.5 mm or greater at baseline, and rapidly progressive CAV as an increase in maximum intimal thickness by 0.5 mm or more at 1 year. Our primary analysis assessed the relationship of IVUS and other clinical data on a composite outcome: coronary intervention, CAV stage 2 or 3 (defined by the International Society for Heart and Lung Transplantation 2010 nomenclature), or cardiovascular death. Among 249 patients (mean age 51.0 ± 12.2 years and 74.3% male) included in the analysis, DTA was detected in 118 patients (51.4%). Over a median follow-up of 6.1 years (interquartile range 4.2-8.0 years), 45 patients met the primary end point (23 percutaneous coronary intervention, 11 CAV 2 or 3, and 11 cardiovascular deaths as first event). DTA and rapidly progressive CAV were not associated with the primary end point, all-cause mortality, or retransplantation. In an additional analysis including post-transplant events, incident rejection was strongly associated with poor outcomes, although cytomegalovirus infection was not.
Conclusions:
In this contemporary cohort, IVUS-derived DTA and rapidly progressive CAV were not associated with medium- to long-term adverse events after heart transplantation.
