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Coronary artery fistula after heart transplantation: a disappearing entity?
1Cardiac Catheterization Laboratories, University of Texas Medical Branch, Galveston 77555-0553, USA.
Insights
Coronary artery fistulas after heart transplant are less common now. Most fistulas resolve over time without complications, suggesting a "watchful waiting" approach is best.
Area of Science:
- Cardiology
- Transplant Surgery
- Vascular Medicine
Background:
- Coronary artery fistulas (CAFs) are a known complication post-heart transplantation.
- Previous studies indicated a high incidence of CAFs detected via angiography.
Purpose of the Study:
- To determine the current incidence of CAFs after heart transplantation.
- To investigate the natural history and clinical outcomes of CAFs in this patient population.
Main Methods:
- Retrospective review of coronary angiograms and clinical data from 480 heart transplant recipients (1980-1990).
- Patients were stratified into early, middle, and late transplant groups for incidence comparison.
- Longitudinal follow-up of patients who developed CAFs, including repeat angiography.
Main Results:
- The 3-year incidence of CAFs was 3.5% (early), 6.9% (middle), and 2.9% (late), with a significant decrease in the late group compared to the early group (P < 0.05).
- In 14 patients with 17 fistulas, no fistula increased in size.
- 71% of CAFs (10 of 14 patients) became angiographically undetectable during a median 6-year follow-up.
- No clinical complications related to CAFs were observed.
Conclusions:
- The incidence of coronary artery fistulas post-heart transplant has decreased, potentially due to improved heart biopsy techniques.
- Coronary artery fistulas in heart transplant recipients typically do not progress and often resolve spontaneously.
- A conservative
- watchful waiting
- strategy is recommended for managing CAFs due to their benign natural history and lack of clinical sequelae.
Abstract:
A high incidence of coronary artery fistulas has been observed angiographically after heart transplantation. To determine the present incidence of this finding and the natural history of fistulas in this setting, we reviewed coronary angiograms and clinical course on all patients (n = 480) transplanted from 1980 to 1990 who survived until the first annual coronary angiogram and compared the incidence of coronary artery fistulas in the early (patients #1-160), middle (patients #161-320), and late transplant (patients #321-480) groups. The 3-yr coronary artery fistula incidence for the early group was 3.5%, 6.9% for the middle group, and 2.9% in the late group (P < 0.05, early vs late). Patients who developed fistulas were followed longitudinally. Angiographic follow-up data (median duration: 6 yr) were available in 14 patients having 17 fistulas. No fistula increased in size, and in 10 of 14 patients (71%), fistulas became angiographically undetectable. No patient had any clinical complication related to the fistula. In summary, the incidence of coronary artery fistulas is presently lower than previously reported, which may in turn be related to refinements in heart biopsy technique. The lack of long-term clinical sequelae and the relatively high rate of disappearance favor a conservative approach of "watchful waiting."