Cardiac allograft vasculopathy natural history, complications and prognosis

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]

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 (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.