Cardiogenic Shock Due to Severe Transplant Vasculopathy in a Heart Transplant Recipient: The Limitations of Computed Tomography Coronary Angiogram

Abstract

We report the case of a 34-year-old male heart transplant recipient who developed cardiogenic shock during invasive coronary angiography due to severe transplant vasculopathy not identified by CT coronary angiogram (CTCA). Prior to coronary angiography, the patient underwent a treadmill stress echocardiogram and a computed tomography coronary angiogram for investigation of shortness of breath on exertion. The stress echocardiogram showed no evidence of inducible myocardial ischaemia at a good workload, and the subsequent CTCA showed no significant coronary artery disease. During selective intubation of the left main with a JL-4 catheter via the femoral approach, the patient had profound haemodynamic compromise and cardiovascular collapse. The patient had cardiopulmonary resuscitation using a LUCAS device and was commenced on VA-ECMO. The patient underwent unsuccessful emergency coronary artery bypass grafting, but was successfully re-transplanted at a later date. Severe transplant vasculopathy despite a normal CTCA was suspected as the underlying cause of cardiovascular collapse, and the macroscopic and histopathologic examination of the heart confirmed this. We conclude that whilst CTCA can provide useful information about the arterial lumen and wall, investigation into non-invasive imaging is ongoing and it remains unclear as to whether it will reduce the need for invasive testing to identify transplant vasculopathy.