Accelerated coronary vascular disease in the heart transplant patient: Coronary arteriographic findings

Abstract

Annual coronary arteriograms have been obtained from all heart transplant recipients at Stanford University Medical Center since 1969. Angiographic lesions in 81 transplant patients exhibiting coronary vascular disease were classified into three categories: type A, discrete or tubular stenoses; type B, diffuse concentric narrowing; and type C, narrowed irregular vessels with occluded branches. The 81 arteriograms showing transplant coronary vascular disease were contrasted with 32 from nontransplant patients with coronary artery disease analyzed in a similar fashion. The nontransplant angiograms showed 178 lesions, all of type A (discrete or tubular) morphology, 75% of which were located in primary epicardial coronary vessels and 25% in secondary branch vessels. In the patients with transplant coronary vascular disease, 349 (76%) of 461 lesions were type A: 57% in primary vessels, 42% in secondary branches and 1.4% in tertiary branches. Of the 112 type B and C lesions (diffuse narrowing, tapering and obliteration), 25% were in primary vessels, 44% in secondary vessels and 31% in tertiary branches (p less than 0.05 for patients with transplant coronary vascular disease versus patients with nontransplant coronary artery disease). Total vessel occlusion was found in proximal or middle vessel segments in 96% and distally in 4% of patients with "ordinary" coronary artery disease versus 49% distally in patients with transplant coronary disease (p less than 0.002). In the presence of total vessel occlusion, collateral vessels were poor or absent in 92% of transplant versus 7% of nontransplant patients with coronary disease (p less than 0.002). Therefore, coronary artery disease in transplant patients represents a mixture of typical atheromatous lesions and unique transplant-related progressive distal obliterative disease that occurs without collateral vessel development.

Oxidized Low Density Lipoproteins in Patients With Transplant-Associated Coronary Artery Disease

“…1,2 This posttransplant arteriopathy is characterized by rapid development, 3,4 concentric narrowing of smaller coronary arteries, 5,6 and the lack of correlation with known atherogenic risk factors. [1][2][3][4][5][6] Understanding the etiology of accelerated atherosclerosis might allow identification of patients at risk for this complication.It has been suggested that ischemic injury of the heart during the peritransplant period significantly contributes to the development of accelerated atherosclerosis in heart transplant patients. 7 A correlation between LDL oxidation and atherogenesis was first suggested by experiments showing that oxidized LDL mediated injury to endothelial cells (reviewed in Reference 8) and was further supported by studies showing a protective effect of antioxidants against progression of atherosclerosis.…”

“…1,2 This posttransplant arteriopathy is characterized by rapid development, 3,4 concentric narrowing of smaller coronary arteries, 5,6 and the lack of correlation with known atherogenic risk factors. [1][2][3][4][5][6] Understanding the etiology of accelerated atherosclerosis might allow identification of patients at risk for this complication.…”

Cutting balloon angioplasty for cardiac transplant vasculopathy

“…[1][2][3] The angiographic characteristic of allograft vasculopathy is defined as diffuse concentric narrowing in the epicardial medium and small arteries. 12 The only definite therapy for such diffuse disease is repeat transplantation, but the survival rate of retransplantation is worse than for initial transplantation and is limited by organ availability. 13 Coronary artery bypass surgery also is of limited value in the diffuse, small-vessel disease manifested in these patients.…”

Does use of intravascular ultrasound accelerate arteriopathy in heart transplant recipients?

“…3,15,16 Serial angiographic studies in heart transplantation recipients have demonstrated an increased prevalence of coronary abnormalities associated with longer graft survival. 6 By 5 years after transplantation, 40% to 50% of patients have angiographic evidence of disease. 6,17…”

“…[1][2][3][4][5][6] Annual coronary angiography, which can detect severe transplantation coronary artery disease (TCAD) as early as 1 to 2 years after heart transplantation, has been used for diagnostic and surveillance purposes because patients may remain asymptomatic until myocardial infarction, congestive heart failure, cardiac arrhythmia, or sudden death develop. 3,7 Angiography is relatively insensitive for detecting early or less severe TCAD because of its diffuse nature and because the early phases of intimal hyperplasia may be associated with vessel wall expansion (positive remodeling) and minimal luminal narrowing.…”