Coronary Angioplasty and Stenting in Orthotopic Heart Transplants: A Fruitful Act or a Futile Attempt?

Abstract

Accelerated allograft coronary artery disease remains the major cause of mortality after the first year of transplantation. Despite the extensive use of stents and angioplasty in coronary artery disease, there is a paucity of data about the efficacy of such interventions in orthotopic heart transplants. The authors herein report the outcome of those patients in their institution who had undergone percutaneous coronary artery angioplasty and stenting at a late stage of their transplantation. Within a 12-year period, 106 adult patients underwent orthotopic heart transplantation at their institution. Eight of these patients with 17 lesions underwent deployment of nine stents and eight angioplasties 8.1 +/- 3.2 years posttransplantation. There were 15 denovo and two restenotic lesions. The indications for intervention were presence of symptoms in five patients and severity of lesions in three asymptomatic patients detected on their follow-up angiogram. All patients had angiographic worsening of lesions at their follow-up angiogram. The initial procedural success for both stented and angioplastied lesions was 100%. Within a mean angiographic follow-up of 261 days, all balloon angioplastied lesions had developed restenosis, whereas within a mean period of 67 days, 50% of stented lesions had developed restenosis. On the follow-up angiogram, deterioration of the nontreated segments were noted throughout the coronary arterial tree; however, the immediate proximal and distal parts of the target segments demonstrated an exaggerated hyperproliferative response as compared to other sites. The overall median time to the detection of restenosis for both stented and angioplastied lesions was 5.2 months (inner quartile 2.5-6.2 months). The authors conclude that angioplasty and stenting late in the course of transplantation is associated with a significant restenosis rate and in such patients earlier or alternative catheter-based interventions must be considered.

Palliation of allograft vasculopathy with transluminal angioplasty

“…Our analysis is in concert with available studies in heart transplant recipients examining the benefit of PTCA with stenting in which restenosis rates at 6 to 12 months are consistently lower with the addition of stents (10,15,16). We found a significant reduction in the freedom from restenosis both early and late after PTCA with nearly a 50% reduction in restenosis at eight months.…”

“…In several smaller studies of cardiac transplant recipients undergoing PCIs, a cumulative of 83 patients underwent PTCA without stenting and Benza et al June 2, 2004June 2, :1973 PTCA and Allograft Vasculopathy demonstrated restenosis rates of 14% to 61% at four to seven months (7)(8)(9)(12)(13)(14) In addition, one multicenter study of 35 patients undergoing PTCA of 95 lesions demonstrated a 55% restenosis rate at seven months. In several later studies in patients undergoing PTCA alone, the restenosis rate at two to six months ranged from 67% to 100% (10,15,16). Unfortunately, in many of these studies, the definitions for restenosis and the duration of follow-up differed, resulting in considerable variability in the restenosis rate.…”

“…Thus, this study comprised 62 patients who underwent 151 procedures (trips to the angioplasty suite) resulting in PCI of 219 lesions. Angiographic follow-up was available in 174 (79%) of these procedures; 45 procedures had no angiographic follow-up because of death (10), retransplantation (7), primary procedural failure (6), or other (10). Angiography.…”

Experience of Percutaneous Coronary Intervention in the Management of Pediatric Cardiac Allograft Vasculopathy

“…In our series, the procedure was associated with 2 major complications (1 death) and a restenosis rate of 82%. Although this is a small series, these results are consid- 1,4,7,8 This may be due in part to their smaller vessels and by necessity the use of smaller stents. In this study, the maximum balloon diameter ranged from 2.0 to 3.25 mm (median, 2.5 mm), and the maximum stent diameter ranged from 2.5 to 3.0 mm (median, 2.75 mm).…”

Management of the ACC/AHA Stage D Patient

“…[14][15][16] Once clinically significant CAV is apparent, percutaneous coronary intervention (PCI) is successful for focal disease, although restenosis is common in the transplant setting. 55 Drug-eluting stents may help, but restenosis rates continue to be higher than for similar interventions in the nontransplant population. 56,57 There is no evidence to date that PCI alters the prognosis of CAV and, because many patients with significant disease are asymptomatic, intervention often presents a dilemma.…”