Coronary computed tomography angiography for the detection of cardiac allograft vasculopathy: a meta-analysis of prospective trials.

Aims Cardiac allograft vasculopathy (CAV) is a major limitation to long-term survival following cardiac transplantation. Conventional imaging modalities such as angiography and intravascular ultrasound fail to characterize CAV plaque morphology. Our aim was to characterize CAV in vivo using the high spatial resolution of intracoronary optical coherence tomography (OCT).

Methods and results We prospectively enrolled 53 cardiac transplant patients to undergo OCT of the left anterior descending coronary artery (LAD) in addition to annual CAV screening by coronary angiography and intravascular ultrasound (IVUS). The proximal 30 mm of the LAD was divided into three segments of 10 mm each ( n = 156). Segments with CAV plaque on IVUS were analysed by OCT for specific CAV morphological characteristics within the framework of three groups according to follow-up time after heart transplantation: (i) 0–3 months ( n = 18), (ii) 12–36 months ( n = 55), and (iii) ≥48 months ( n = 83). The prevalence of atherosclerotic characteristics such as eccentric plaques, calcification, and lipid pools increased from 6, 0, and 6% in group 1 to 78, 42, and 61% in group 3, respectively (all P < 0.001). The prevalence of vulnerable plaque features such as thin-cap fibroatheroma, macrophages, and microchannels increased from 0% in group 1 to 12, 29, and 33% in group 3, respectively ( P = 0.19, P = 0.006, and P = 0.003). Complicated coronary lesions such as intimal laceration, intraluminal thrombus, and layered complex plaque increased from 0% in group 1 to 18, 19, and 57% in group 3 ( P = 0.009, P < 0.001, and P < 0.001). Plaque rupture was identified in 4% of group 3 segments.

Conclusion The current study gives new insight into CAV that extends far beyond the current concept of concentric and fibrosing vasculopathy, that is, the development of atherosclerosis with vulnerable plaque and complicated coronary lesions.

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Coronary atherosclerosis with vulnerable plaque and complicated lesions in transplant recipients: new insight into cardiac allograft vasculopathy by optical coherence tomography

Long-term outcomes and management of the heart transplant recipient.

Background Optical coherence tomography (OCT) is a novel intravascular imaging modality with excellent spatial resolution. This study explored the utility of OCT in cardiac transplantation for the detection and characterization of early changes associated with coronary allograft vasculopathy (CAV). Methods Fifteen consecutive patients, 1 to 4 years after transplant with no angiographic evidence of CAV, underwent successful OCT imaging using the Fourier-domain OCT system (C7-XR, St. Jude Medical, St. Paul, MN) in the left anterior descending artery. Analysis included measurements of the lumen, intima, and media layers, and characterization of atherosclerotic plaques. Patients were stratified by intima-to-media (I/M) ratio and classified as normal (≤1) or abnormal (>1). Results Patients were a mean of 2.8 years after transplant, 58 years old, and 92% were men. OCT imaging revealed 8 of 15 patients had intimal hyperplasia with an I/M ratio >1. Comparing those with I/M ratio of ≤1 and >1, the median (interquartile range) intimal thickness was greater (75 [70–101] vs 206 [97–269]μm, p = 0.03), whereas the media thickness was no different (72 [70–103] vs 94 [73–113]μm, p = 0.53). In addition, 7 of 15 patients had lipid-rich or calcified atherosclerotic plaques. Conclusions OCT provides high-resolution quantitative imaging of the coronary arteries and its use allows for detailed assessment of the coronary artery wall and early morphologic changes that occur after cardiac transplantation. The clinical predictive value of these OCT-derived measurements remains to be determined.

Optical coherence tomography for characterization of cardiac allograft vasculopathy after heart transplantation (OCTCAV study)

State of the art: cardiac transplantation.

Background Cardiac allograft vasculopathy (CAV) is a major factor limiting long-term survival after heart transplantation (HT). The purpose of this study was to characterize the coronary artery structure and to determine the prevalence of vasculopathy after HT, comparing the sensitivity of coronary angiography with that of intravascular ultrasound (IVUS) and virtual histology (VH). Methods A prospective recruitment cross-sectional study was performed in 31 adult HT recipients including 22 men and, 9 women of overall mean age of 45.2 ± 12.6 years at an average of 3.7 ± 3.7 years after transplantation. They underwent simultaneously coronary angiography and IVUS assessment of the left anterior descending coronary artery. We investigated histological composition of the intima. Final data were analyzed using parametric and nonparametric tests. Results IVUS discovered the presence of CAV among 17/31 (54.8%) patients versus coronary angiography in 10 (32.3%; P = .009). The histological composition of the intima as assessed with IVUS VH was 26.1% fiber, 8.7% necrotic core, 5.7% calcium, and 4.3% lipid. There was no significant association between preexistent risk factors and the presence of CAV. There was a correlation between time elapsed since HT and CAV development. Conclusion Time elapsed since HT is the most important risk factor for the development of CAV. Its prevalence almost doubled when measured with IVUS in contrast with angiography. IVUS was thus shown to be a more sensitive diagnostic tool compared with coronary angiography.

Prevalence of Cardiac Allograft Vasculopathy Assessed With Coronary Angiography Versus Coronary Vascular Ultrasound and Virtual Histology

Microvascular Coronary Flow Comparison in Acute Myocardial Infarction Angioplasty treated with a mesh covered stent (MGUARD Stent) versus Bare Metal Stent: MICAMI–MGUARD

We report a 16 year old male with a history of angina on exertion.A treadmill exercise test was positive for ischemia in concordance with a Thallium-201scintigraphy showing a septal and infero-posterior reversible myocardial perfusion defect.Coronary angiography disclosed severe aneurysmal coronary artery disease. Bilateral internalmammary coronary artery bypass grafting was successfully performed. Kawasaki disease is themost likely etiology, although not confirmed (Rev Med Chile 2007; 135: 1182-85).(

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Enfermedad coronaria aneurismática severa en un adolescente con angina de esfuerzo secundaria a enfermedad de Kawasaki no diagnosticada previamente

Shock cardiogénico refractario: rescate con ECMO, asistencia ventricular y trasplante

Use of cyclosporin A has improved survival in patients submitted to cardiac transplantation. However, high cost of cyclosporin poses a problem for many patients in Chile. Ketoconazole is able to reduce hepatic metabolism of cyclosporin and thus prolong therapeutic levels. A 74 to 82% reduction in cyclosporin requirements was obtained in a cardiac transplant patient by adding ketoconazole. No renal damage was detected. Therefore, this drug association may help extend cardiac transplantation programs in Chile.

Humberto Torres

Papers

Prevalence of Cardiac Allograft Vasculopathy Assessed With Coronary Angiography Versus Coronary Vascular Ultrasound and Virtual Histology

Microvascular Coronary Flow Comparison in Acute Myocardial Infarction Angioplasty treated with a mesh covered stent (MGUARD Stent) versus Bare Metal Stent: MICAMI–MGUARD

Enfermedad coronaria aneurismática severa en un adolescente con angina de esfuerzo secundaria a enfermedad de Kawasaki no diagnosticada previamente

Shock cardiogénico refractario: rescate con ECMO, asistencia ventricular y trasplante

[Cardiac transplantation: economizing cyclosporin A by including ketoconazole in the immunosuppressive schedule].