Cardiac allograft vasculopathy natural history, complications and prognosis
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Cardiac allograft vasculopathy Microchapters |
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Differentiating Cardiac allograft vasculopathy from other Diseases |
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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
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.
- 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
- Arrhythmias
Prognosis
Survival
- Overall 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. However, the risk adjusted Kaplan-Meier curves suggests a significant improvement in long term survival in recent years.
- Re-transplantation: Patients who underwent re-transplantation between 2002 to 2006, who were more than 12 months from their index transplantation had a 1 year survival of approximately 85%, which is the same as index transplants performed during that period.
Causes of death
The following table outlines the common causes of death in post cardiac transplant patients:
| First 30 days post-transplant | From 1 month to 12 months post-transplant | After 5 years post-transplant |
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Cardiac allograft vasculopathy
- The Kaplan-Meier curves from data collected by The 25th official report by Heart and Lung Transplant Registry, demonstrates a steady increase in the incidence of CAV post-transplant, such that only 46% of patients are free from angiographic evidence of CAV at the end of 10 years. Moreover, the survival after development of CAV appears to have minimal improvement in recent years in comparison to immediately preceding years.
- Early CAV (diagnosed within 1 year post-transplant) was a powerful predictor of 5 year mortality.
- According to ISHLT Registry, higher donor age, younger recipient age, history of hypertension, pre-transplant diagnosis of ischemic heart disease, HLA-DR mismatches were important predictors for development of CAV.