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Revascularization procedures in patients with transplant coronary artery disease
V S Patel1, B Radovancevic, W Springer
1Texas Heart Institute at St. Luke's Epsicopal Hospital, Houston 77030, USA.
Insights
Revascularization effectively treats de novo coronary artery disease in heart transplant recipients. Coronary angioplasty and atherectomy are preferred for single lesions, while laser therapy shows promise for complex cases.
Area of Science:
- Cardiology
- Transplant Medicine
- Interventional Cardiology
Background:
- De novo coronary artery disease (CAD) is a significant complication after cardiac transplantation.
- Graft vasculopathy and accelerated atherosclerosis contribute to CAD development in transplant recipients.
Purpose of the Study:
- To evaluate the effectiveness of various revascularization strategies in cardiac transplant patients diagnosed with de novo coronary artery disease.
- To compare the outcomes of percutaneous transluminal coronary angioplasty (PTCA), percutaneous transluminal coronary rotational atherectomy (PTCRA), coronary artery bypass grafting (CABG), and transmyocardial laser revascularization (TMLR).
Main Methods:
- Eighteen cardiac transplant recipients with de novo CAD underwent revascularization using PTCA, PTCRA, CABG, or TMLR.
- Procedures included 11 PTCA, 6 PTCRA, 5 CABG, and 2 TMLR (one combined with CABG).
- Patient data included time post-transplant, stenosis severity, ejection fraction, and presence of hypertrophy.
Main Results:
- PTCA achieved successful stenosis reduction in 10 procedures, with 2 cases of restenosis at follow-up.
- PTCRA was successful in all patients with no short-term reocclusion.
- CABG had a high mortality rate (3/5 patients), particularly in those with hypertrophy. TMLR showed improvement in symptoms and ejection fraction in select patients.
Conclusions:
- Revascularization can be effective for de novo CAD in heart transplant patients.
- Coronary angioplasty or atherectomy are recommended for single proximal lesions.
- CABG should be used cautiously, reserved for multi-vessel disease without hypertrophy.
- Laser revascularization holds potential as a primary therapy for transplant CAD.
Objective:
To assess the efficacy of revascularization in cardiac transplant patients who developed de novo coronary artery disease.
Methods:
Eighteen patients underwent one or more of four methods of revascularization: percutaneous transluminal coronary angioplasty (PTCA), percutaneous transluminal coronary rotational atherectomy (PTCRA), coronary artery bypass grafting (CABG), and transmyocardial laser revacularization (TMLR). Eleven PTCA procedures were performed in 10 patients 55.3 +/- 6.6 months after transplantation. Six patients underwent PTCRA 83.3 +/- 11.2 months after transplantation. Five patients underwent CABG 54.0 +/- 12.6 months after transplantation; the mean left ventricular ejection fraction was 49.6 +/- 16.9 (20-65%); hypertrophy was present in two of these patients. One patient with distal coronary artery disease and New York Heart Association class IV symptoms underwent TMLR only. One patient underwent both CABG and TMLR because of triple vessel proximal disease, diffuse distal disease, and New York Heart Association class IV symptoms.
Results:
PTCA was successful in 10 procedures with decrease in mean stenosis from 87.7 +/- 2.7 to 24.3 +/- 6.0%. Follow-up, at 16.9 +/- 4.0 months, showed restenosis in two patients. PTCRA was successful in all patients with a decrease in mean stenosis from 83.4 +/- 4.4 to 11.7 +/- 1.9%. Short-term follow-up did not reveal reocclusion. Two CABG patients who had hypertrophy died of heart failure 2 and 9 days after their operations. One CABG patient with excellent cardiac function died after 15 days because of pulmonary failure. In one patient, left ventricular ejection fraction improved from 35 to 50%, and he is alive 64 months later. Six months after TMLR, the New York Heart Association class in one patient improved from IV to II, and his left ventricular ejection fraction improved from 29 to 42%. The ejection fraction in the patient who underwent both CABG and TMLR improved from 20 to 56% but the patient expired 7 weeks later.
Conclusions:
It appears that revascularization procedures can be effective in patients with coronary artery disease after cardiac transplantation and that coronary angioplasty or atherectomy would be a therapy of choice for single proximal lesions. CABG should be used cautiously and only reserved for patients with multi-vessel disease without hypertrophy. Laser revascularization with or without bypass grafting has potential to become the therapy of choice for transplant coronary artery disease.