Cardiac allograft vasculopathy natural history, complications and prognosis
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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
CAV is responsible for approximately 40% of deaths in heart transplant recipients. Survival in these patients has improved significantly over the decades, owing primarily to improved diagnostic techniques, and optimal immunosuppression and risk factor modification. The 2013 adult heart transplant registry noted that 5-year survival in both pediatric and adult heart transplant recipients is 69%.
Natural History
- CAV is a slowly progressive disease of the graft vessels. However it may progress rapidly in some post-transplant patients. For example, about 7% of patients from the Cardiac Transplant Research Database had severe disease that progressed rapidly by the end of 5 years.
- In a few years post-transplant, the disease progresses from clean coronary vasculature to diffusely diseased, obstructive pattern.
- A 5 year prospective study by Tsutsui and colleagues using intravascular ultrasound (IVUS) revealed that most of the intimal thickening in CAV develops during the first year after heart transplantation [1].
- Late onset of CAV is infrequent. The process of development of CAV is rather slow in those who develop CAV 10 years post-transplant.
Complications
Most of the complications of CAV are related to myocardial hypoperfusion. These include:
- Graft failure
- Myocardial infarction
- Sudden death
- Congestive heart failure (sometimes in the form of rapidly developing systolic failure)
- Arrhythmias
Prognosis
- All-cause mortality data from 1982 up to June 2011 shows 1 year survival of 81% and 5 year survival of 69%, with median survival of 10 years for all and 13 years for those surviving until the end of first year. The most recent cohort of patients show unadjusted 1 year survival of 84%.
- The survival curve demonstrates a steep fall in survival in the first 6 months post-transplant. Thereafter, it steadily decreases by 3.5% per year and continues to do so well beyond 15 years. Presence of CAV is the strongest predictor of mortality in patients who survive beyond 1 year post-transplant.
- The ISHLT Registry showed that CAV together with late graft failure was responsible for about 33% of deaths 5 years post-transplant.
- Also the survival of patients with CAV has in fact improved over the last decade.
References
- ↑ Tsutsui H, Ziada KM, Schoenhagen P, Iyisoy A, Magyar WA, Crowe TD; et al. (2001). "Lumen loss in transplant coronary artery disease is a biphasic process involving early intimal thickening and late constrictive remodeling: results from a 5-year serial intravascular ultrasound study". Circulation. 104 (6): 653–7. PMID 11489770.