Cardiac allograft vasculopathy: diagnosis, therapy, and prognosis

Skorić, Boško and Čikeš, Maja and Ljubas Maček, Jana and Baričević, Željko and Škorak, Ivan and Gašparović, Hrvoje and Biočina, Bojan and Miličić, Davor (2014) Cardiac allograft vasculopathy: diagnosis, therapy, and prognosis. Croatian Medical Journal, 55 (6). pp. 562-576. ISSN 0353-9504

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Abstract

Development of cardiac allograft vasculopathy represents the major determinant of long-term survival in patients after heart transplantation. Due to graft denervation, these patients seldom present with classic symptoms of angina pectoris, and the first clinical presentations are progressive heart failure or sudden cardiac death. Although coronary angiography remains the routine technique for coronary artery disease detection, it is not sensitive enough for screening purposes. This is especially the case in the first year after transplantation when diffuse and concentric vascular changes can be easily detected only by intravascular ultrasound. The treatment of the established vasculopathy is disappointing, so the primary effort should be directed toward early prevention and diagnosis. Due to diffuse vascular changes, revascularization procedures are restricted only to a relatively small proportion of patients with favorable coronary anatomy. Percutaneous coronary intervention is preferred over surgical revascularization since it leads to better acute results and patient survival. Although there is no proven long-term advantage of drug-eluting stents for the treatment of in-stent restenosis, they are preferred over bare-metal stents. Severe vasculopathy has a poor prognosis and the only definitive treatment is retransplantation. This article reviews the present knowledge on the pathogenesis, diagnosis, treatment, and prognosis of cardiac allograft vasculopathy.

Abstract in Croatian

Vaskulopatija srčanog alografta:dijagnoza, terapija i prognoza ----- Razvoj vaskulopatije srčanog alografta predstavlja osnovnu odrednicu dugoročnog preživljenja kod pacijenata nakon presađivanja srca. Zbog denervacije presatka, ovi pacijenti rijetko imaju klasične simptome angine pektoris, tako da su prve kliničke prezentacije progresivno zatajenje srca i iznenadna srčana smrt. Iako je koronarna angiografija i dalje rutinska metoda za otkrivanje bolesti koronarnih arterija, ona nije dovoljno osjetljiva za svrhu probira. Ovo je posebice čest slučaj u prvoj godini nakon presađivanja kada se difuzne i koncentrične vaskularne promjene mogu s lakoćom otkriti samo uz pomoć intravaskularnog ultrazvuka. S obzirom da se vaskulopatija teško liječi, treba se primarno posvetiti ranoj prevenciji i dijagnostici. Zbog difuznih vaskularnih promjena, revaskularizacija se može provesti samo kod malog broja pacijenata koji imaju zadovoljavajuću anatomiju srca. Perkutanoj koronarnoj intervenciji daje se prednost u odnosu na kiruršku revaskularizaciju jer ona dovodi do boljih akutnih rezultata i preživljenja pacijenata. Također, proširnicama koje izlučuju lijek daje se prednost u odnosu na metalne proširnice iako nisu dokazane njihove dugoročne prednosti kod liječenja ponovnog suženja unutar ugrađene proširnice. Prognoza uznapredovale vaskulopatije nepovoljna je te je jedini učinkovit način liječenja presađivanje srca. Ovaj članak daje pregled dostupnog znanja o patogenezi, dijagnozi, liječenju i prognozi vaskulopatije srčanog alografta.

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