Cardiac allograft vasculopathy surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2]; Raviteja Guddeti, M.B.B.S. [3]

Overview[edit | edit source]

Surgery[edit | edit source]

Nonpharmacologic Interventions[edit | edit source]

• Retransplantation
• Percutaneous coronary interventions
• Coronary artery bypass grafting (CABG)
• Transmyocardial revascularization
• Heparin induced/mediated extracorporeal LDL plasmapheresis (HELP)

Retransplantation[edit | edit source]

• Retransplantation is the only definitive treatment for CAV. It is associated with satisfactory survival in patients with CAV.
• About 60% of the repeat transplantation procedures performed are due to graft failure secondary to CAV ^[1]. It is a higher risk procedure and raises significant ethical concerns primarily because of scarcity of heart transplant donors ^[2].
• Prognosis: One year survival has improved in recent years, but continues to be inferior compared to primary transplants (79% in re-transplant group compared to 85% in primary transplant group) ^[3].

Percutaneous Coronary Intervention[edit | edit source]

• This procedure is limited only to a selected group of patients with focal disease in a single artery. Moreover, the number of patients who benefit are small.
• Incidence of re-stenosis is high, ranging from 20 to 60% as reported in various studies.
• Intracoronary stenting appears to have lower rate of re-stenosis as compared to coronary angioplasty alone.
• Concomitant use of high dose immunosuppressive therapy with azathioprine and mycophenolate have shown to significantly reduce the rate of re-stenosis ^[4].

Coronary Artery Bypass Grafting[edit | edit source]

• Associated with a high perioperative mortality especially in those with distal disease.
• In a retrospective analysis of 12 patients with CAV who underwent CABG, 4 died perioperatively, while only 7 were alive at the end of 9 months post-surgery ^[5].

Transmyocardial Revascularization[edit | edit source]

• Also known as transmyocardial laser revascularization (TMLR), is a procedure involving creation of transmural channels in the myocardium to enhance blood supply.
• This procedure has been studied in multiple clinical trials in patients with refractory angina and those who are not considered as surgical candidates.
• Mehra and colleagues ^[6] first studied the effects of TMLR in patients with diffuse CAV. They reported significant improvement in symptoms and anginal class at 4 and 8 week follow up. However, at 24 month follow up, the procedure showed neither consistent symptomatic improvement nor any change in course of the progression of CAV ^[7].

Heparin Induced/Mediated Extracorporeal LDL Plasmapheresis[edit | edit source]

• Also known as LDL apheresis.
• Leads to significant reductions in LDL, lipoprotein(a) levels and fibrinogen.
• No effect on HDL levels.
• In a prospective study by Park et al., patients treated with LDL apheresis had a statistically significant increase in intraluminal diameter between 1 year and 2.5 years of follow up. However, long term trials are required to draw firm conclusions.

References[edit | edit source]

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