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Eur J Cardiothorac Surg 2006;29:862-863
© 2006 Elsevier Science NL
Letter to the Editor |
Department of Cardiothoracic Surgery, Glasgow Royal Infirmary, 16 Alexandra Parade, Glasgow G31 2ER, UK
Received 1 January 2006; accepted 26 January 2006.
* Tel.: +44 141 2114731/5645206; fax: +44 141 5520987/2114845. (Email: mishrapk_25{at}yahoo.com).
Key Words: Cardiac transplant • Coronary allograft vasculopathy • Noninvasive diagnosis
I read with interest recent article by Caus et al. [1]. It is an interesting article which provides valuable insight into this promising noninvasive diagnostic modality. I would like to add a few comments.
Many previous studies created a gloomy picture about the sensitivity and specificity of currently available noninvasive tests in the diagnosis of coronary allograft vasculopathy (CAV) [2]. The poor predictive ability of noninvasive tests in this population was probably due to the fact that these tests were designed to detect effects of ischemia rather than coronary obstruction alone [2]. This particular technique described by the authors has the potential to diagnose CAV before the appearance of angiographically detectable lesions. The authors need to be congratulated.
The demographic data provided do not mention the age of the recipients either at the time of transplant or at the time of study. Donor age and organ age (donor age + time since transplant) are relevant but do the authors mean that recipient age at the time of study was not relevant? They have discussed the recipient risk factors for coronary artery disease (CAD) (smoking, hypertension, etc.). Do they have the demographic data for donor risk factors for CAD? Atherosclerosis is a progressive disease and prevalence of CAD risk factors in donors will have impact on development of CAV in recipients [3]. Mean time between the heart transplant and the study was around 7 years but the incidence of CAV was only 30%, which was quite low as compared to the generally reported incidence of around 50% after 5 years of transplantation [4]. It will be interesting to know what the authors think about the possible reasons for low incidence of CAV in their patients. Besides, what is the usual protocol for angiography in their post-transplant patients? Some centres have abandoned annual surveillance angiography and rely on radionuclide studies and angiography is performed only if the patient is symptomatic or noninvasive reports are suspicious [5]. Were the patients included in this study picked up by routine surveillance angiography or was the angiography indicated because of patient's symptoms?
I was a bit baffled by the definition of CAV used as inclusion criteria by the authors. The conclusions drawn from such cohort of patients will have little impact on diagnosis and management of a substantial number of post-transplant patients. The definition and classification used by Costanzo et al. [3] seems to be of more clinical value. At the end of the day newer investigations should alter treatment options. We are not going to gain anything by making a diagnosis if the management plan remains the same. There is no dispute that medical management for prevention of CAV is warranted in any case in all post-transplant patients.
We need further studies so that the concept of early detection of CAV leading to modulation of immunosuppressive regimens (as suggested by the authors) with an improved late survival after transplant could come out of the realm of wishful thinking. Prevention currently relies heavily on modification of nonimmunologic factors only.
References
This article has been cited by other articles:
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  T. Caus Reply to mishra. Eur. J. Cardiothorac. Surg., May 1, 2006; 29(5): 863 - 864. [Full Text] [PDF]
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