Abstract
Background: Graft coronary disease (GCD) remains the Single greatest limitation to long-term
survival of heart transplant recipients. Therapeutic strategies for the prevention
or retardation of GCD in the cardiac allograft are limited; palliative coronary revascularization
has been attempted. Because of the high mortality rate associated with advanced forms
of GCD our institution offers the option of retransplanation in selected cases. The
aim of this study was by analyzing retrospectively the outcomes of angioplasty, coronary
bypass grafting, and retransplantation in cardiac transplant patients to attempt to
identify subgroups of transplant recipients with graft coronary disease who may profit
from myocardial revascularization. Methods: Of the 989 patients undergoing 1016 heart transplantations (HTx) at our institution
between 10/86 and 12/97, all were screened for the development of GCD. Analyzing routinely
annual angiography, intracoronary ultrasound in defined study patients, and autopsy
findings, GCD was diagnosed in 124 patients (110 male, 14 female) 2 to 107 months
after HTx (mean 30 months). Results: PTCA: Fourty-six out of 124 patients underwent 76 angioplasties at a mean of 50 ±
30 months (range 4-91 mo) following cardiac transplantation. The primary success rate
was 96% (73/76). The reason for the unsuccessful angioplasty attempts (n = 3) was
failure to completely penetrate a stenosis of LAD in 2 patients and severe dissection
of RCA, which required emergency surgery, in one. Angiographic restenosis occurred
in 42% (31 of 76 lesions) and was diagnosed 11 ± 11 months after the first angioplasty.
There was no procedure-related death. CABG: Seven patients underwent bypass surgery
at a mean of 67 months (range 6 -128 months) after HTx. Elective surgery was performed
in 2 patients with proximal severe triple-vessel disease (Type A lesion) and in 1
patient with severe tricuspid regurgitation who reeeived a tricuspid valve replacement
and concomitant single-vessel bypass surgery for proximal GCD (Type A lesion). One
patient with combined Type A and B/C lesions required emergency surgery for dissection
of RCA after an angioplasty procedure. Three patients with post-infarction unstable
angina developed worsening congestive heart failure which required emergency surgery.
Angiographically all these patients showed diffuse, distal arteriopathy (combined
Type B/C lesions). The electively operated patients and the patient with dissection
of RCA were successfully treated and survived beyond hospital discharge (overall survival
for CABG in GCD patients 4/7 = 57%). After a mean follow-up of 10 months (range 2-32
months) all are in good clinical condition. All 3 patients with distal arteriopathy
and emergency surgery died in hospital of left-ventricular failure (43%). Retransplantation:
Eight patients underwent retransplantation at a mean of 54 months (range 6-96 months)
after HTx. Six of 8 patients had successful operations and survived beyond hospital
discharge with a one-year-survival rate of 75%. In a mean follow-up of 31 months (5-68
months) 3 of 6 retransplant recipients developed a recurrence of GCD. Conclusion: The presence of angiographic distal arteriopathy should be considered a significant
factor in patient selection for coronary revascularization procedure. Coronary angioplasty
is to be considered as a method of treatment for severe, local stenoses (Type A lesion).
PTCA may be applied in these selected cardiac transplant recipients with primary success
and complication rates comparable to routine angioplasty but with an increased rate
of restenosis especially in small vessels (diameter < 2.5 mm). The distinction between
Type A lesions in large (diameter ≥ 2.5 mm) and small vessels may be important not
only with respect to restenosis but also with respect to long-term benefit. The overall
survival did not differ between GCD patients with and without PTCA, suggesting this
treatment to be largely palliative. Coronary artery bypass grafting can successfully
be performed in a subgroup of cardiac transplant patients with Type A lesions. However,
the state of diffusely diseased distal arteries (Type B/C lesions) prevalent in this
group of patients and resulting in low cardiac Output limits the use of bypass surgery.
Retransplantation is recommended for severe diffuse disease with poor left-ventricular
funetion and Symptoms of increasing heart failure.
Key words
Heart transplantation - Graft coronary disease - Coronary artery bypass grafting -
Percutaneous transluminal coronary angioplasty - Retransplantation
