Treatment of unprotected left main coronary artery stenosis with a drug eluting stent in a heart transplant patient with allograft vasculopathy

Abstract

High risk angioplasty with drug eluting stent placement into an unprotected left main coronary artery in a heart transplant recipient with allograft vasculopathy is reported. Ten month angiographic follow up is reported. The literature is reviewed and current methods of revascularisation are described in detail. This is the first report of drug eluting stent use in this clinical situation.A llograft vasculopathy is the main cause of death in heart transplant recipients surviving the first year of transplantation.1 Medical treatment has very limited efficacy in preventing allograft vasculopathy.2 3 Coronary artery bypass grafting (CABG) is seldom possible because of the diffuse nature of the disease and is often a high risk procedure, carrying a 40-80% perioperative mortality. Retransplantation has worse prognosis than the first transplant procedure and is limited by a severe shortage of donor organs. Therefore, percutaneous coronary intervention (PCI) has been attempted and good immediate success and a varying rate of restenosis have been reported.Unprotected left main coronary artery balloon angioplasty is technically feasible but procedural and three year mortality rates are high: 9% and 64% for elective cases, and 50% and 70% for acute myocardial infarction. [7][8][9] Stenting improved procedural success rates (. 95%) in highly selected patients and improved restenosis in 14-23%. 10 For elective stenting in patients with left ventricular ejection fraction . 40%, 86% event-free survival was reported at six months. 7 We report the first case of the treatment of unprotected left main coronary artery stenosis in a heart transplant recipient with drug eluting stent placement. CASE REPORTSignificant allograft vasculopathy of the left main coronary artery was diagnosed in a 58 year old man. Subjective symptoms were worsening fatigue and decreasing exercise capacity. A dobutamine echocardiogram showed normal baseline systolic function and no wall motion abnormalities with stress. Coronary angiogram showed significant focal coronary artery disease in the proximal segments of the left anterior descending, circumflex, and right coronary arteries, as well as a shelf-like plaque in the proximal to mid-left main stem ( fig 1A, B). The focal nature of obstructive lesions in the proximal coronary tree made angioplasty a technically feasible alternative. The patient had had three previous sternotomies for open heart surgery. Because of the high risk of CABG in this clinical presentation, the patient requested a staged series of angioplasties instead of another operation.The patient's medical history was significant for orthotopic heart transplantation in 1989 for valvar cardiomyopathy, hypertension, and hypercholesterolaemia. The patient had had a single episode of documented grade 1A, focal, mild, acute cellular rejection in 2001. Home medications were aspirin, clopidogrel, atenolol, pravastatin, amiodarone, prednisone, and cyclosporine. Complete blood count and a metabolic panel, including normal serial creatinine concentra...

Comparison of Percutaneous Coronary Intervention With Bare-Metal and Drug-Eluting Stents for Cardiac Allograft Vasculopathy

“…One patient underwent repeat OHT. Published data also include 3 case reports of PCI with DES for CAV, including a patient treated for in-stent restenosis of a BMS (36), a patient with significant left main disease (37), and a patient with acute myocardial infarction (38).…”

Angina secundaria a lesión de tronco coronario izquierdo post trasplante cardiaco: Evidencias de reinervación simpática tardía

“…Las tasas de reestenosis parecen ser mayores para las angioplastias que usaron stents metálicos (31%) al compararlos con los stents con drogas (15%-19%) 16,17 . En cuanto a la angioplastia con stent del TCI en el paciente con corazón trasplantado la experiencia es limita-da requiriendo en la mayoría de ellos cirugía de revascularización posterior pese a uso de stent con drogas 18,19 . En nuestro paciente, el procedimiento de angioplastia del TCI fue exitoso en el corto plazo.…”

Long-term clinical outcomes after percutaneous coronary intervention for unprotected left main coronary artery in heart transplant patients with cardiac allograft vasculopathy

“…Initial search resulted in 347 citations. The titles and abstracts of these citations were reviewed for patients with CAV and a total of 12 reports were selected for detailed review [17][18][19][20][21][22][23][24][25][26][27][28]. The reference lists of these reports were also reviewed.…”

“…Of these 12 manuscripts (mostly case reports and case series), two reports [27,28] were excluded as they reported outcomes on the same patients at different follow-up periods. The 10 remaining reports [17][18][19][20][21][22][23][24][25][26] were thoroughly reviewed, and data on baseline clinical and socio-demographic characteristics, coronary anatomy and stent type (drug eluting vs. bare metal) were extracted. Primary clinical outcome of interest was all-cause death.…”