The Journal of Heart and Lung Transplantation
Cardiac allograft vasculopathy after heart transplantation: risk factors and management
Section snippets
Cardiac allograft vasculopathy
Cardiac allograft vasculopathy (CAV), a type of cardiovascular disease that occurs uniquely in transplant recipients, is a rapidly progressive form of atherosclerosis characterized in its early stages by intimal proliferation and in its later stages by luminal stenosis of epicardial branches, occlusion of smaller arteries and myocardial infarction.5 Myocardial ischemia and infarction secondary to CAV in transplant patients are usually silent, due to a lack of cardiac innervation. Instead of
Immunologic risk factors for CAV
The risk of CAV increases as the number of HLA mismatches and the number and duration of rejection episodes increases.16 The occurrence of ≥2 major rejection episodes has been significantly associated with an increased prevalence of CAV assessed by arteriography or pathologic examination (Figure 1).2, 17, 18 Even recurrent mild rejection in the first 3 months after transplantation may increase the risk of intimal thickening according to IVUS.19 In a sophisticated study using IVUS, donor
Non-immunologic risk factors for CAV
Various non-immunologic factors have been associated with development of CAV after transplantation. For example, heart transplant recipients with cytomegalovirus (CMV) infection, whether symptomatic or not, more frequently have CAV, which is often more severe, than those without CMV infection.21 Donor- or recipient-related factors (e.g., age/gender, pre-transplant diagnosis) and those related to surgery (ischemia–reperfusion injury) also increase the risk of CAV.22, 23 In addition, the risk of
Management of CAV
Once CAV has developed, the only definitive treatment is re-transplantation, which has risks for the patient and poses an ethical dilemma for the clinician in view of the scarcity of donor organs. Other surgical approaches, such as stenting and angioplasty, may have a high re-stenosis rate and expose the patient to the risks of another surgical procedure.54, 55 Such procedures are inherently likely to be less effective than in non-transplant patients because of the diffuse nature of CAV
Conclusions
Cardiovascular risk, particularly of ischemic heart disease, is significantly increased in heart transplant recipients. This risk is a combination of pre-existing factors plus those that result from surgical intervention and immunosuppression. In particular, exposure to cardiovascular risk factors, such as hypertension, hyperlipidemia and new-onset diabetes after transplantation, can promote the development of CAV. Atherosclerotic narrowing of graft blood vessels may result in graft ischemia
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