Coronary Artery Vasculopathy in a Cohort of Heart Transplant Recipients: A Single Center Experience

Abstract

Background: Coronary allograft vasculopathy (CAV) is a significant cause of late mortality in heart transplant recipients. This study assesses the development of CAV, associated rejection rates, and the potential impact of percutaneous coronary intervention (PCI) on survival in a cohort of heart transplant patients.

Methods: We conducted a retrospective analysis of 321 patients who underwent orthotropic heart transplantation (OHT) at Virginia Commonwealth University between October 2008 and September 2021. Data on CAV incidence, PCI, rejection, and mortality were collected. CAV severity was classified by ISHLT criteria, and Kaplan-Meier analysis was used to evaluate survival.

Results: CAV occurred in 55 patients (17%), with a median onset of 2.81 years. Nineteen of these patients required PCI, including three for chronic total occlusion (CTO). Overall mortality was higher in the CAV group compared to the non-CAV group (40% vs. 27%, p = 0.045). Kaplan-Meier analysis revealed no overall survival difference between CAV and non-CAV patients (p = 0.558). Excluding patients with less than 2 years of follow-up, survival significantly favored the non-CAV group (5-year survival: 93% vs. 86%; 10-year survival: 75% vs. 62%, p = 0.023). Patients with CAV who underwent PCI had survival outcomes comparable to those with less severe CAV (p = 0.75). One case involved a 67-year-old female with a right coronary artery CTO, successfully treated with PCI, which maintained vessel patency for an additional 2 years and potentially preserved allograft function.

Conclusion: CAV is a late complication associated with increased mortality, especially in those with moderate to severe rejection. PCI in patients with advanced CAV may help improve survival to levels comparable with less severe CAV. Further research is needed to better understand non-immunologic factors and the role of PCI in long-term outcomes.

Keywords: chronic total occlusion (CTO); coronary allograft vasculopathy (CAV); heart transplant; mortality; percutaneous intervention (PCI); rejection; survival analysis.

Figure 1

Distribution of 321 orthotropic heart transplantation (OHT) patients by coronary artery vasculopathy (CAV), percutaneous coronary intervention (PCI) and rejection status along with indicating mortality status in each group. *Difference in mortality between CAV and Non‐CAV group was statistically significant (p = 0.045). **Difference in mortality between PCI and Non‐PCI group was not statistically significant (p = 0.42). [Color figure can be viewed at wileyonlinelibrary.com]

Figure 2

Rate and grade of rejection in patients with Coronary Artery Vasculopathy (CAV). AMR, antibody mediated rejection; CR, cellular rejection. [Color figure can be viewed at wileyonlinelibrary.com]

Figure 3

(a) Dual right and left coronary injections showing right coronary artery (RCA) complete total occlusion at the level of the ostium. Proximal‐mid segment is visualized via collateral flow supplied from distal left anterior descending artery (LAD), septals, and Vieussens' collaterals from the proximal LAD. (b) RCA after successful intravascular ultrasound‐guided intervention with three drug‐eluting stents.

Figure 4

Intravascular ultrasound imaging showing significant fibrotic plaque throughout the right coronary artery. [Color figure can be viewed at wileyonlinelibrary.com]

Figure 5

Overall Survival and Survival Stratified by Coronary Artery Vasculopathy (CAV) status and follow‐up time. (a) Kaplan−Meier Survival Curve for Overall Cohort (b). Kaplan−Meier Survival stratified by CAV status (p = 0.45) (c). Kaplan−Meier Survival by CAV Status in patients with > 1‐year follow‐up (p = 0.06) (d). Kaplan−Meier Survival by CAV Status in patients with > 2‐year follow‐up (p = 0.023).

Figure 6

(a) Kaplan−Meier survival in Coronary Artery Vasculopathy (CAV) patients by Percutaneous Coronary Intervention (PCI) group. (a) All Patients had 1 year or greater follow‐up (p = 0.753). (b) Patients with > 2‐year follow‐up (p = 0.65).