What Should be the Treatment Approach in Patients with Cardiac Allograft Vasculopathy?

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Abstract

Introduction

Cardiac allograft vasculopathy (CAV) is one of the major survival factors and the most important cause of mortality after cardiac transplantation. CAV may be defined as vascular disease resulting from immunological mechanisms that operate in the environment of non-immunologic risk factors. What can we do in patients with allograft vasculopathy? Stenting, coronary bypass grafting (CABG) or medical follow-up?

Materials and Method

Seven patients diagnosed from 125 heart transplant patients who were treated in our clinic between January 2003 and June 2017 were retrospectively evaluated. According to the clinical protocol, CAV was diagnosed by coronary angiography performed annually. Cellular and humoral rejections were evaluated in patients who underwent biopsy according to clinical protocol. In patients with CAV, tacrolimus was replaced by sirolimus for immunosuppression. The effects of our treatment approaches (coronary interventional procedures, coronary artery bypass grafting and medical therapy) on survival were studied in these patients.

Results

The mean age of the patients was 28 (min 12, max 33), the mean follow-up period was 9.1 years and mean CAV development time was 5.6 years. Of these patients, 2 had cellular and 2 had cellular and humoral rejections. 2 patients underwent coronary artery stenting, 3 patients underwent CABG (one patient who had previously undergone stenting), while 3 patients were followed up medically. One patient underwent retransplantation 2 years after CABG. One patient who underwent CABG was died in the early postoperative period. There was no change in the control angiography of the follow-up patients.

Discussion

Typical lesions of CAV are composed of intimal proliferations leading to obstruction especially in small and medium arteries, which causes myocardial ischemia by decreasing graft blood flow. In a cardiac transplant patient, it is difficult to diagnose CAV because of the absence of innervation in the heart, and in CAV-diagnosed patients, the treatment is quite complicated. Especially concentric, diffuse and distal vessel involvement is the most important factor limiting the feasibility of the revascularization protocols.

Conclusion

Each patient who develops CAV must be evaluated individually and then the most appropriate treatment should be decided.

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