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DOI: 10.1055/s-0032-1332368
Non-stenotic coronary vasculopathy is associated with reduced survival after heart transplantation
Objective: The ISHLT working formulation for cardiac allograft vasculopathy (CAV) is a largely stenosis-based classification, while the consensus statement of the German task force also evaluates non-stenotic lesions. We determined the impact of non-stenotic vasculopathy on survival after heart transplantation.
Methods: Coronary angiograms (n = 1480, 906 pts) performed at 30 days, 1, 5, 10, 15 and 20 years post-transplant were evaluated according to the ISHLT (CAV0-CAV3) and the German task force (stenosis, large vessel tapering, peripheral obliteration) working formulations.
Results: CAV0 was present in 85%, 77%, 45%, 23%, 16% and 16% of pts at 30 days, 1, 5, 10, 15 and 20yrs post-transplant. CAV1 was found in 15%, 21%, 45%, 58%, 50% and 42% of pts, respectively. CAV2 and CAV3 were uncommon during the first post-transplant year but affected 10%, 19% and 35% of pts at 5, 10 and 15yrs after transplant. Peripheral obliteration affected 46%, 36%, 57%, 63%, 71% and 74% of pts at 30 days, 1, 5, 10, 15 and 20yrs post-transplant. Positive remodeling was found in 5%, 5%, 9%, 14%, 19% and 13% of pts at 30 days, 1, 5, 10, 15 and 20yrs after transplant. Negative remodeling was present in 5%, 14%, 36%, 48%, 52% and 38% of pts at 30 days, 1, 5, 10, 15 and 20yrs post-transplant.
Higher ISHLT class was associated with poor overall survival if diagnosed at 1 (p < 0.001), 5 (p = 0.04), or 10yrs (p = 0.08) post-transplant. Peripheral obliteration was associated with poor survival if present at 1 (p = 0.002), 5 (p < 0.001), 10 (p = 0.09) or 15yrs (p = 0.03) post-transplant. Tapering of the left coronary artery was associated with reduced survival in coronary angiograms performed at 1 (p < 0.001), 5 (p = 0.06), and 10yrs (p = 0.003) post-transplant. Tapering pattern of the right coronary artery was correlated with reduced survival only at 10 years post-transplant (p = 0.016). Positive remodeling (as compared to negative remodeling) was not associated with improved survival.
Conclusion: Non-stenotic vasculopathy is common after heart transplantation and is associated with reduced post-transplantation survival. The evaluation of distal coronary artery disease and tapering appears to complement the ISHLT working formulation.