European Journal of Cardio-Thoracic Surgery, Vol 10, 528-532, Copyright © 1996 by European Association for Cardio-thoracic Surgery
The management of post-cardiac transplantation coronary artery disease
A Parry, M Roberts, J Parameshwar, J Wallwork, P Schofield and S Large
Transplant Unit, Papworth Hospital, Papworth Everard, Cambridge, England.
OBJECTIVE: Allograft coronary artery disease remains the single greatest
limitation to long term survival after cardiac transplantation. It is
peculiarly aggressive in its behavior and diffuse in its nature. The role
of conventional approaches to coronary artery revascularisation were
studied in a selected group of cardiac transplant recipients. METHODS: Of
the 557 patients undergoing cardiac transplantation at our unit between
January 1979 and December 1993, all were screened for the development of
allograft coronary artery disease routinely after 2 years and yearly
thereafter or after 4 years. Twenty patients with allograft coronary artery
disease were considered suitable for treatment by conventional means 17 of
whom had undergone transplantation for ischaemic cardiomyopathy and the
others for dilating cardiomyopathy. Percutaneous transluminal coronary
angioplasty was performed in 18, 25-103 months after transplantation (mean
60 months) all of whom had severe proximal stenoses and reversible defects
on perfusion scans. None suffered chest pain. Coronary artery bypass
grafting was performed in 5, 95-105 months after transplantation (mean 101
months) 2 of whom had post-infarction unstable angina and 3 had severe
triple vessel disease, dyspnoea, and perfusion abnormalities. RESULTS: The
primary success rate for PTCA was 84% (16/19). Two lesions restenosed and 3
patients had progressive disease which necessitated coronary
revascularisation. No patient died. Of the 5 patients undergoing coronary
artery surgery 2 died perioperatively, one from acute left ventricular
failure and one from acute rejection. All 18 survivors have improved
perfusion scans. Following surgery, all survivors had improvement in
dyspnoea and relief of angina. Five late deaths a mean of 89 months after
transplantation were from coronary artery disease (4) and lung malignancy
(1). CONCLUSIONS: Revascularisation by PTCA and CABG is feasible and
successful in selected cardiac transplant recipients. Further study is
required to determine the effect of revascularisation on prognosis.
