Cardiac Allograft Vasculopathy Is Less Frequent in Contemporary Heart Transplant Population

Abstract

Purpose Coronary allograft vasculopathy (CAV) remains an important contributor of mortality following orthotopic heart transplantation (OHT). Prevalence of epicardial coronary stenosis ≥30% at 5 years post OHT is reported to be 30%. The purpose of this study was to define the prevalence of CAV in a contemporary cohort. Methods and Materials We studied 432 consecutive coronary angiograms of patients transplanted from 1994-2011 (87.3% transplanted after January 2000). Baseline characteristics were obtained from medical records. CAV status was classified according to the International Society for Heart and Lung Transplantation grading report: mild (CAV1), moderate (CAV2), or severe (CAV3). Unpaired t test and Fisher’s exact test were used for statistical analysis. Results During a mean angiographic follow-up period of 5.2±4.3 years (all follow-up ≥1 year), angiographic stenosis ≥30% was identified in 70 (16%) patients. Mean time to development of epicardial coronary stenosis ≥30% was 5.8±3.9 years. Prevalence of coronary stenosis ≥30% at 1 year was 1.6%, at 3 years 6.3%, at 5 years 8.3%, and at 10 years 14.1%. CAV1 severity was identified in 33 (7.6%) patients, CAV2 in 25 (5.8%) patients and CAV3 in 12 (2.8%) patients. Percutaneous coronary intervention was necessary in 5.8% of all patients. Mean transplant age (55±12 years), donor age (32±12 years), gender (22% female), ischemic time (185±70 minutes) and choice of calcineurin inhibitor (tacrolimus vs cyclosporine) were not significantly different between patients with and without CAV. Patients with CAV were more likely to have had cellular or humoral rejection within the first year of transplant than patients without CAV [13/70 (19%) vs 25/362 (6.9%), p=0.0043]. Conclusions The prevalence of allograft vasculopathy appears to have decreased in a large contemporary cohort compared to prior reports. Rejection continues to play a role in CAV formation but may not be the only contributing factor. Further investigation is warranted to ascertain which aspect(s) of clinical care has contributed to this positive outcome.