Cardiac allograft vasculopathy surgery

Cardiac allograft vasculopathy Microchapters

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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

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## Surgery

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### Nonpharmacologic Interventions

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

#### Retransplantation

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* 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

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* 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

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* 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

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* 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

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* 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

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1. ↑ Mehra MR (2006). "Contemporary concepts in prevention and treatment of cardiac allograft vasculopathy". Am J Transplant. 6 (6): 1248–56. doi:10.1111/j.1600-6143.2006.01314.x. PMID 16686747.
2. ↑ Radovancevic B, McGiffin DC, Kobashigawa JA, Cintron GB, Mullen GM, Pitts DE; et al. (2003). "Retransplantation in 7,290 primary transplant patients: a 10-year multi-institutional study". J Heart Lung Transplant. 22 (8): 862–8. PMID 12909465.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
3. ↑ Srivastava R, Keck BM, Bennett LE, Hosenpud JD (2000). "The results of cardiac retransplantation: an analysis of the Joint International Society for Heart and Lung Transplantation/United Network for Organ Sharing Thoracic Registry". Transplantation. 70 (4): 606–12. PMID 10972218.CS1 maint: Multiple names: authors list (link)
4. ↑ Benza RL, Zoghbi GJ, Tallaj J, Brown R, Kirklin JK, Hubbard M; et al. (2004). "Palliation of allograft vasculopathy with transluminal angioplasty: a decade of experience". J Am Coll Cardiol. 43 (11): 1973–81. doi:10.1016/j.jacc.2004.02.045. PMID 15172400.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
5. ↑ Halle AA, DiSciascio G, Massin EK, Wilson RF, Johnson MR, Sullivan HJ; et al. (1995). "Coronary angioplasty, atherectomy and bypass surgery in cardiac transplant recipients". J Am Coll Cardiol. 26 (1): 120–8. PMID 7797740.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
6. ↑ Malik FS, Mehra MR, Ventura HO, Smart FW, Stapleton DD, Ochsner JL (1997). "Management of cardiac allograft vasculopathy by transmyocardial laser revascularization". Am J Cardiol. 80 (2): 224–5. PMID 9230169.CS1 maint: Multiple names: authors list (link)
7. ↑ Mehra MR, Uber PA, Prasad AK, Park MH, Scott RL, McFadden PM; et al. (2000). "Long-term outcome of cardiac allograft vasculopathy treated by transmyocardial laser revascularization: early rewards, late losses". J Heart Lung Transplant. 19 (8): 801–4. PMID 10967275.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)

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