The management of post-cardiac transplantation coronary artery disease

Abstract

Allograft coronary artery disease remains the single greatest limitation to long term survival after cardiac transplantation. It is peculiarly aggressive in its behavior and diffuse in its nature. The role of conventional approaches to coronary artery revascularisation were studied in a selected group of cardiac transplant recipients. Of the 557 patients undergoing cardiac transplantation at our unit between January 1979 and December 1993, all were screened for the development of allograft coronary artery disease routinely after 2 years and yearly thereafter or after 4 years. Twenty patients with allograft coronary artery disease were considered suitable for treatment by conventional means 17 of whom had undergone transplantation for ischaemic cardiomyopathy and the others for dilating cardiomyopathy. Percutaneous transluminal coronary angioplasty was performed in 18, 25-103 months after transplantation (mean 60 months) all of whom had severe proximal stenoses and reversible defects on perfusion scans. None suffered chest pain. Coronary artery bypass grafting was performed in 5, 95-105 months after transplantation (mean 101 months) 2 of whom had post-infarction unstable angina and 3 had severe triple vessel disease, dyspnoea, and perfusion abnormalities. The primary success rate for PTCA was 84% (16/19). Two lesions restenosed and 3 patients had progressive disease which necessitated coronary revascularisation. No patient died. Of the 5 patients undergoing coronary artery surgery 2 died perioperatively, one from acute left ventricular failure and one from acute rejection. All 18 survivors have improved perfusion scans. Following surgery, all survivors had improvement in dyspnoea and relief of angina. Five late deaths a mean of 89 months after transplantation were from coronary artery disease (4) and lung malignancy (1). Revascularisation by PTCA and CABG is feasible and successful in selected cardiac transplant recipients. Further study is required to determine the effect of revascularisation on prognosis.