Role of Percutaneous Intervention in Treatment of Proximal Cardiac Allograft Vasculopathy as Compared to Diffuse Distal Disease

Abstract

Purpose Cardiac allograft vasculopathy (CAV) is a progressive diffuse form of arterial narrowing affecting patients with orthotopic heart transplants (OHT). The outcome of patients undergoing PCI for proximal CAV in comparison to patients with distal non-intervenable disease is currently unknown. Methods and Materials All patients undergoing OHT and subsequent coronary angiography at the Cleveland Clinic were considered for inclusion. Subjects were divided into three cohorts: no/ mild CAV, moderate or severe diffuse CAV without revascularization, severe CAV with revascularization. Kaplan Meier survival analysis was utilized for group comparisons. Results Data from 282 patients (222 M, 60 F) including 1759 angiographies were used for analysis. During the study period, 96 PCI were performed in 51 patients. CABG and repeat OHT were performed in 5 and 4 patients respectively. Mean (SD) duration to first revascularization was 8.8 (5.0) years. 84 patients had evidence of early CAV, defined as at least moderate CAV within the first 10 years after OHT. Very early CAV (>moderate CAV within 5 years of OHT) occurred in 43 subjects. Patients with proximal CAV requiring PCI had a significantly reduced survival as compared to patients with moderate or severe distal diffuse disease not amenable to PCI (p=0.04) or those with no/ mild CAV (p=0.005). Median survival after first revascularization was 5.7 years. Repeat revascularization was needed in 20 patients (2 procedures in 12 patients, 3 procedures in 7 patients, 4 procedures in 1 patient). There was no significant difference in median survival after PCI among patients with very early CAV, early CAV or late CAV. Median survival in these three groups was measured as 6.8 years, 5.5 years and 5.8 years respectively (p=0.4). Conclusions Patients with proximal CAV requiring PCI had lower survival as compared to those with diffuse distal disease, which is not amenable to revascularization. The median survival after PCI appears to be constant, regardless of the time of occurrence of CAV after OHT.