Abstract
Heart transplantation (HT) is an accepted treatment for end-stage heart failure (HF). Heart transplantation significantly increases survival, exercise capacity, quality of life and return to work in selected patients with advanced heart failure compared with conventional treatment. The survival rates have improved with the use of new immunosuppressive drugs, with a median survival after transplantation of approximately 11 years. The shortage of donor hearts represents a major limitation in this field. In addition many are the consequences of the limited effectiveness and complications of immunosuppressive therapy (i.e. antibody-mediated rejection, infection, hypertension, renal failure, malignancy and coronary artery vasculopathy). In particular, chronic rejection may occur months to years after the transplantation and is referred to as cardiac allograft vasculopathy (CAV). CAV occurs in 32% of the patients after 5 years and ensuing allograft failure from CAV eventually accounts for 30% of recipient deaths after transplantation. Cardiac allograft vasculopathy, involving coronary macro- and microcirculation, is caused by complicated interplay between immunologic and non-immunologic factors resulting in repetitive endothelial injury and localized sustained inflammatory response. Early diagnosis of microvascular dysfunction is substantial. In this review we analyze signs and symptoms of CAV presentation and the different methodologies to achieve an early and precise diagnosis. We will discuss invasive and non-invasive diagnostic tools and their specific role in evaluating graft’s function, morphology, the presence of coronary artery disease and possible microcirculation involvement.
Highlights
Heart transplantation (HT) is an accepted treatment for end-stage heart failure (HF)
Chronic rejection is referred to as cardiac allograft vasculopathy (CAV); based on the ISHLT registry, CAV occurs in 32% of the patients after 5 years and ensuing allograft failure from CAV eventually accounts for 30% of recipient deaths after transplantation [2]
Echocardiography can highlight new wall motion abnormalities that could be associated with the presence of CAV; late reduction of left ventricle ejection fraction (LVEF) is often associated with progression of CAV with a subsequent poor prognosis [21]
Summary
Heart transplantation (HT) is an accepted treatment for end-stage heart failure (HF). Patients may manifest unique clinical complications (associated with the immunosuppressive therapy and cardiac allograft rejection) as well as atypical clinical presentations for infections and systemic inflammatory response syndrome. Chronic rejection is referred to as cardiac allograft vasculopathy (CAV); based on the ISHLT registry, CAV occurs in 32% of the patients after 5 years and ensuing allograft failure from CAV eventually accounts for 30% of recipient deaths after transplantation [2]. Cardiac denervation at the time of heart transplantation usually prevents patients from experiencing angina, which is an important warning sign for heart disease Because of this lack of typical symptoms, transplant patients with CAV usually present with silent myocardial infarction, loss of allograft function or sudden death [13]. Current guidelines indicate angiography, coupled with the assessment of graft function, as the imaging procedure of choice for CAV diagnosis and classification and to predict long-term prognosis
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