New developments for the detection and treatment of cardiac vasculopathy

Clerkin, Kevin J.; Ali, Ziad A.; Mancini, Donna

doi:10.1097/hco.0000000000000388

Cited by 19 publications

(11 citation statements)

References 94 publications

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“…CAV is one of the most common causes for long-term mortality. Besides non-immunological damage such as ischemia reperfusion injury, infection and hypertension, immune-mediated injury due to antibody-mediated and cellular rejection can lead to CAV [ 10 ]. Invasive and non-invasive evaluation showed an incidence of CAV of 17%, which is comparable with incidences evaluated in a large international registry: Stehlik and colleagues reported an incidence of 20% at 3-year follow-up in patients transplanted between 2001 and 2009.…”

Section: Discussionmentioning

confidence: 99%

Lower frequency routine surveillance endomyocardial biopsies after heart transplantation

et al. 2017

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In heart transplantation (HTx) patients, routine surveillance endomyocardial biopsies (rsEMB) are recommended for the detection of early cardiac allograft rejection. However, there is no consensus on the optimal frequency of rsEMB. Frequent rsEMB have shown a low diagnostic yield in the new era of potent immunosuppressive regimen. Efficacy and safety of lower frequency rsEMB have not been investigated so far. In this retrospective, single centre, observational study we evaluated 282 patients transplanted between 2004 and 2014. 218 of these patients were investigated by rsEMB and symptom-triggered EMB (stEMB). We evaluated EMB results, complications, risk factors for rejection, survival 1 and 5 years as well as incidence of cardiac allograft vasculopathy (CAV) 3 years after HTx. A mean of 7.1 ± 2.5 rsEMB were conducted per patient within the first year after HTx identifying 7 patients with asymptomatic and 9 patients with symptomatic acute rejection requiring glucocorticoide pulse therapy. Despite this relatively low frequency of rsEMB, only 6 unscheduled stEMB were required in the first year after HTx leading to 2 additional treatments. In 6 deaths among all 282 patients (2.1%), acute rejection could not be ruled out as a potential underlying cause. Overall survival at 1 year was 78.7% and 5-year survival was 74%. Incidence of CAV was 17% at 3-year follow-up. Morbidity and mortality of lower frequency rsEMB are comparable with data from the International Society for Heart and Lung Transplantation (ISHLT) registry. Consensus is needed on the optimal frequency of EMB.

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Section: Discussionmentioning

confidence: 99%

Lower frequency routine surveillance endomyocardial biopsies after heart transplantation

et al. 2017

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“…Therefore, identifying factors that are associated with early CAV is critical to improve long‐term outcomes. Although costly and operator dependent, intravascular ultrasound (IVUS) provides a more sensitive diagnostic test for evaluating early CAV compared with conventional angiography 4 . The presence of intimal thickening by IVUS has been shown to be predictive of future clinical events 5‐10 .…”

Section: Introductionmentioning

confidence: 99%

“…Although costly and operator dependent, intravascular ultrasound (IVUS) provides a more sensitive diagnostic test for evaluating early CAV compared with conventional angiography. 4 The presence of intimal thickening by IVUS has been shown to be predictive of future clinical events. [5][6][7][8][9][10] Rapidly progressive CAV (as defined by an increase in maximal intimal thickness (MIT) by 0.5 mm within the first year is associated with increased mortality and myocardial infarction when compared to a lesser degree of thickening.…”

Section: Introductionmentioning

confidence: 99%

Risk factors for early development of cardiac allograft vasculopathy by intravascular ultrasound

Moayedi

Fan

Tremblay-Gravel

et al. 2020

Clinical Transplantation

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Background: Cardiac allograft vasculopathy (CAV) is the leading cause of late graft loss. While there are numerous post-transplant factors which may increase the risk of the development of CAV, there is a paucity of data on the impact of donor-derived atherosclerosis (DA), early discontinuation of prednisone, and early initiation of proliferation signal inhibitors (PSI) as assessed by intravascular ultrasound (IVUS). Methods: Retrospective single-center study of all adult transplant patients (2008-2017) with serial IVUS at baseline and annually for 5 years. DA was defined as a baseline maximal intimal thickness (MIT) ≥0.5 mm, and CAV development was defined as MIT ≥1 mm or an increase in MIT ≥0.5 mm at year 1 compared with baseline or an increase in 0.3 mm annually thereafter. Clinical risk factors for CAV were identified using multivariable hazard regression. Separate multistate models were applied to assess the association of prednisone discontinuation and PSI initiation and CAV. Results: Of 282 patients screened, 186 patients had a 1-year angiogram. The mean age of those included in the cohort was 51 ± 11 years, 70% were male, 58% were Caucasian, and 27% were supported by a left ventricular assist device. Donor atherosclerosis was present in 40%. The cumulative incidence of CAV at 5 years is 41% in DA-vs. 59% in DA + (p = .012). Donor age was a strong predictor of DA (p = .016). Significant risk factors for CAV included male sex (HR = 4.141, p = .001), non-Caucasian race (HR = 1.98, p = .011), BMI < 18 kg/m2 (HR = 4.596, p = .042), longer ischemic time (HR = 1.374, p = .028), older donor age (HR = 1.158, p = .009), and rejection with hemodynamic compromise within the first year (HR = 2.858, p = .043).

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“…As HTX patients are mostly angina free, coronary stenosis is sometimes a random finding and often accompanies the graft rejection process. The main pathomechanism of coronary stenosis in the graft is an autoimmunologic inflammatory response and infection causing vascular inflammation leading to endothelial dysfunction [7][8][9][10].…”

Section: Clinical Researchmentioning

confidence: 99%

Coronary revascularization after heart transplant – the search for prognostic factors

Guzik

Szczepanek

Niewiara

et al. 2020

aoms

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Introduction: Survival after heart transplantation (HTX) is extended due to continuous improvement of medical care, allowing enough time for coronary artery vasculopathy to develop. Data on the clinical outcome of cardiac transplantation patients after percutaneous coronary intervention (PCI) are still not extensively explored. The aim of our study was to assess whether heart transplantation itself compromises the outcome in patients undergoing percutaneous coronary intervention and to assess survival rates as well as major cardiovascular complications in heart transplant recipients who had undergone PCI. Material and methods: Thirty-three heart transplant recipients who had undergone PCI in the years 2005 to 2015 in a single center were matched by age, sex and main risk factors of arteriosclerosis with 33 controls without heart transplant history. Mean age of patients was 54.6 ±11.4 years in the HTX group and 58.8 ±10.8 years in controls. Median time from heart transplant to PCI was 13 years (4.4-22 years). Case and control groups did not differ in terms of standard risk factors of coronary artery disease, apart from chronic kidney disease, which was present in 70% of patients after heart transplantation, and dyslipidemia, which was present in 91% of control subjects. Results: Patients after HTX had worse survival compared to controls (p = 0.04). When adjusted for comorbidities in the Cox regression model, there was no significant difference in survival between cardiac transplant recipients and the control group (HR = 1.06; 95% CI: 0.10-11.24). Chronic renal disease was a significant predictor of all-cause mortality (HR = 29.9; 95% CI: 2.3-393). Considering other endpoints, HTX patients had considerably higher incidence of severe bleeding compared to the control group (27% vs. 3%, p < 0.05). Conclusions: There was no significant difference in myocardial infarction rate, revascularization or hospitalization rates.

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New developments for the detection and treatment of cardiac vasculopathy

Cited by 19 publications

References 94 publications

Lower frequency routine surveillance endomyocardial biopsies after heart transplantation

Lower frequency routine surveillance endomyocardial biopsies after heart transplantation

Risk factors for early development of cardiac allograft vasculopathy by intravascular ultrasound

Coronary revascularization after heart transplant – the search for prognostic factors

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