Coronary Angioplasty, Bypass Surgery, and Retransplantation in Cardiac Transplant Patients with Graft Coronary Disease

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