New therapeutic option for cardiac ischemia in transplant vasculopathy: spinal cord stimulation

Abstract

The main limitation to long-term survival for allogeneic heart transplant recipients is the onset of “accelerated allograft coronary artery disease” (ACAD). Over the years, different treatment options for the management of ACAD-induced critical ischemia have been taken into consideration. The use of percutaneous transluminal coronary angioplasty (PTCA) is still controversial, performed mostly for Type B/C and Type A lesions measuring 2.5 mm. According to Musci et al, there is no difference between PTCA-treated and non–PTCAtreated patients with ACAD. Myocardial re-vascularization surgery is burdened with high peri-operative mortality and poor long-term results. Transmyocardial laser re-vascularization initially provided encouraging short-term results, but these were not borne out by long-term outcome. In consideration of the increasing number of potential heart transplant recipients and the limited donors pool, which is not increasing proportionally, re-transplantation does not appear to be an ethically sufficient option, because a second transplantation entails a far higher short-term mortality than a first transplantation and is accompanied by a high probability of coronary artery disease (CAD) recurrence. The good outcome reported in the literature and our own experience since 1986 in the management of refractory angina with spinal cord stimulation (SCS) has led us to use this technique in posttransplantation CAD as well. To our knowledge SCS treatment for cardiac transplant recipients has not been reported to date. The Brussels Consensus Statement on SCS in 1998 stated that “to be accepted for SCS treatment, angina pectoris must be refractory both to drug therapy (beta-blockers, calcium channel antagonists, long action nitrates, aspirin) and revascularization methods.” We report a 32-year-old man (weight 58 kg, height 168 cm) who underwent orthotopic cardiac transplantation in February 1992 because of dilated cardiomyopathy, which was diagnosed 2 years earlier and probably had a viral etiology. Post-transplantation follow-up revealed hyperlipoproteinemia, hyperuricemia with sporadic episodes of gout, and obesity. During the 4 years after surgery the patient’s tolerance to the allograft was good. Following the onset of diastolic hypertension and atypical chest pain, left cardiac catheterization with coronary angiography was performed in July 1996. Hemodynamic study showed lesion-free coronary arteries. In January 2000 the patient’s weight increased to 97 kg. Also, he complained of chest pain, typical of exercise-induced angina. The pain was “band-like,” retrosternal, with short duration, and decreased at rest (CCS Functional Class II to III). One month From the Divisions of Pain Therapy and Palliative Care, and Cardiac Surgery, University of Turin, Turin, Italy. Submitted June 11, 2002; revised February 13, 2003; accepted February 13, 2003. Reprint requests: Paolo Centofanti, MD, Divisione di Cardiochirurgia, Ospedale Molinette, C.so A.M. Dogliotti 14, 10126 Turin, Italy. E-mail: paolocentofanti@tiscalinet.it Copyright © 2004 by the International Society for Heart and Lung Transplantation. 1053-2498/04/$–see front matter doi:10.1016/S1053-2498(03)00151-7