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Review
. 2005 Aug;48(4):319-27.

Cardiac allograft vasculopathy: a review

Danny Ramzy  1 , Vivek Rao, Julie Brahm, Santiago Miriuka, Diego Delgado, Heather J Ross
Affiliations
Review

Cardiac allograft vasculopathy: a review

Danny Ramzy et al. Can J Surg. 2005 Aug.

Abstract
in English, French

Cardiac allograft vasculopathy (CAV) is a major factor limiting long-term survival after cardiac transplantation. CAV is an accelerated form of coronary artery disease (CAD) that is characterized by concentric fibrous intimal hyperplasia along the length of coronary vessels. Both immunologic and nonimmunologic risk factors contribute to the development of CAV by causing endothelial dysfunction and injury eventually leading to progressive intimal thickening. The diagnosis of CAV remains a challenge as angiography, the standard method for detecting focal plaques, lacks sensitivity in detecting CAV, and intravascular ultrasonography, a more sensitive method, lacks the ability to evaluate the entire coronary tree. The disease is difficult to treat and results in significant morbidity and mortality. Since treatment of CAV is limited and usually involves repeat transplantation, prevention or mitigation of immunologic and nonimmunologic risk factors is critically important. CAV prevention may involve therapy that provides protection against endothelial injury implemented just before transplantation, during storage and transplantation as well as after transplantation. This review addresses the frequency of occurrence, pathophysiology, diagnosis and treatment of CAV, highlighting areas of active research.

La vasculopathie de l'allogreffon cardiaque (VAC) est un facteur important qui limite la survie à long terme après une transplantation cardiaque. La VAC est une forme accélérée de coronaropathie caractérisée par une hyperplasie fibreuse concentrique de la tunique interne des vaisseaux coronariens. Des facteurs de risque immunologiques et non immunologiques contribuent à l'apparition de la VAC en causant une dysfonction de l'endothélium et une lésion qui entraÎne éventuellement l'épaississement progressif de la tunique interne. La VAC est toujours difficile à diagnostiquer, car l'angiographie, méthode normalisée de détection de la plaque focale, n'est pas assez sensible pour détecter la VAC; l'échographie intravasculaire, plus sensible, ne permet pas d'évaluer l'arbre coronarien au complet. La maladie est difficile à traiter et entraÎne un taux important de morbidité et de mortalité. Comme le traitement de la VAC est limité et entraÎne habituellement une nouvelle transplantation, il est crucial de prévenir ou d'atténuer les facteurs de risque immunologiques et non immunologiques. La prévention de la VAC peut faire appel à une thérapie qui protège contre les lésions endothéliales et est mise en œuvre immédiatement avant la transplantation, pendant l'entreposage et la transplantation, ainsi qu'après l'intervention. Cette critique porte sur la fréquence de l'occurrence, la pathophysiologie, le diagnostic et le traitement de la VAC et met en évidence les domaines où des recherches actives sont en cours.

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Figures

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FIG. 1. Pathophysiology of cardiac allograft vasculopathy (CAV). CHF = congestive heart failure, CHOL = cholesterol, CNI = calcineurin inhibitors, DM = diabetes mellitus, HHcy = hyperhomocysteinemia, HTN = hypertension, MI = myocardial infarction.
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FIG. 3. Survival during the first year after cardiac transplantation. Treatment with pravastatin significantly ( p = 0.025) improved survival compared with controls. Solid line = control, dotted line = pravastatin. Reproduced with permission from Kobashigawa JA, Katznelson S, Laks H, Johnson JA, Yeatman L, Wang XM, et al. Effect of pravastatin in outcomes after cardiac transplantation. N Engl J Med 1995;333:621-7.
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FIG. 2. Maximal intimal thickness 1 year after cardiac transplantation. Pravastatin significantly attenuated intimal proliferation during the first year after transplantation. White = baseline, grey = increase from baseline to 1 year. Reproduced with permission from Kobashigawa JA, Katznelson S, Laks H, Johnson JA, Yeatman L, Wang XM, et al. Effect of pravastatin in outcomes after cardiac transplantation. N Engl J Med 1995;333:621-7.
See this image and copyright information in PMC

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