The Gift That Keeps on Giving? The Impact of Donor Coronary Atherosclerosis on the Development of Coronary Allograft Vasculopathy by IVUS

Abstract

Purpose Cardiac allograft vasculopathy (CAV) is a leading cause of late graft loss . While there are numerous risk factors for the development of CAV, there is a paucity of data on the impact of donor derived atherosclerosis (DA), particularly as assessed by intravascular ultrasound (IVUS). Methods Retrospective single center study of all adult transplant patients (2008-2017) with serial IVUS at baseline and annually upto 5 years. DA was defined as a baseline maximal intimal thickness (MIT) ≥ 0.5 mm, CAV development was defined as MIT ≥ 1 mm or an increase in MIT ≥ 0.5 mm at year 1 or an increase in 0.3 mm annually thereafter. Clinical risk factors for CAV were identified using parametric hazard regression. Separate multistate models were applied to assess the association of prednisone discontinuation, proliferation signal inhibitors (PSI) initiation with CAV. Results Of 284 patients transplanted, 186 patients survived and had an IVUS at 1 year. Mean age of 51 ± 11 years, 70% male, 58% Caucasian with 27% supported by LVAD and 40% had DA. Patients who developed CAV at 1-year had longer ischemic times (4 vs. 3.7 hours, p=0.03), DA+ (65% vs. 39%, p=0.047) and older donor age (40 vs. 33 years, p=0.03). The 5-year cumulative incidence of CAV 41% in DA- vs. 59% in DA+ (Fig 1A). Significant risk factors for CAV were male sex HR 4.1, non-Caucasian race HR 2, underweight (BMI hemodynamic rejection within 1 year HR 2.9. Initiation of PSI within 2 years for reasons other than CAV resulted in fewer cases of CAV HR 0.40 p Conclusion In patients with a baseline and yearly IVUS, DA was more prevalent HR 2 in recipients who developed CAV. Reductions in CAV were seen in patients who discontinued prednisone in the first year or had early PSI initiation for reasons other than CAV. Early IVUS results may allow physicians to tailor immunosuppression and potentially delay progression of CAV.