Aims Cardiac allograft vasculopathy (CAV) is an important cause of morbidity and mortality among transplant (Tx) recipients. (graft loss and death). CAV occurs in approximately 30% of patients at 5 years and 50% at 10 years.
The pathogenesis is given by a diffuse fibroproliferative disease of the heart vasculature of transplant recipients. Percutaneous treatment is useful in focal atherosclerotic lesions but its usefulness in vasculopathy is uncertain.Methods and results Methods
Retrospective cohort in one center of heart transplant patients (115) and CAV undergoing percutaneous treatment of graft vasculopathy was performed between January 2011 and December 2023. Clinical, echocardiographic, and interventional procedure data were reviewed. Procedural success was defined as percutaneous interventional procedure (PIC) and absence of major complications. Actuarial survival within 365 days from procedure was reviewed from the national civil registry database.
Results:
Six patients were included. Age was 54 ± 14 years (range: 47-68), 5 were male, 1 had hypertension, 2 had diabetes mellitus, 1 had chronic kidney failure and 2 had dyslipidemia. Graft vasculopathy was diagnosed 22 ± 10 months after transplant: 3 had CAV 3, 1 had CAV 2 and 1 had CAV 1.
1 patient had injuries in all 3 vessels, 3 patients in 2 vessels and 2 patients in 1 vessel. The affected artery corresponded 6 anterior descending artery, 3 circumflex artery and 2 right coronary artery.
Intravascular imaging was performed in 5 of the 6 patients. In 1 patient it was decisive for the diagnosis (atherosclerotic pathology). A functional study (iFR) was performed in 1 patient and decisive for performing percutaneous treatment in a moderate lesion.
21 PIC were performed. Mediana 4 per patient (range 1 – 12). The average time from Tx to PIC was 102.5 months (16 to 170). PIC was performed with DES (drug-eluting stent) in 3 patients, DEB (drug-eluting balloon) in 2 patients, and 1 patient received combined DES and DEB therapy. The average length is 21.86 mm and the average width is 3.0 mm. 10 DES with xirolimus-eluting stent and 5 with everolimus. From PIC with DEB the average length was 20 mm and the average width was 3.0 mm. The main drug released corresponded to xirolimus in 4 and paclitaxel in 2.
The angiographic result was successful in 100% of the interventions (TIMI 3). Coronary dissection occurred in 1 intervention (DES), being treated with PCI with DES.
The follow-up restenosis occurred in 2 patients. 5 of 6 patients had preserved left ejection fraction (LVEF) and 1 patient with LVEF 28%. Actuarial survival within 4 years of procedures revealed 1 patient presented rejection and cardiovascular deaths.Conclusions Our result shows the heterogeneity of vascular compromise and clinical behavior regarding the revascularization strategy. Intravascular images were decisive in characterizing the type of lesion and the size of the platform to guide revascularization. During follow-up, stent restenosis was the main complication. Survival was acceptable with 1 cardiovascular death.
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