Cardiac allograft vasculopathy in pediatric heart transplant recipients

Metabolic parameters for coronary allograft vasculopathy (CAV) have not been well defined in children. CAV (by angiography or autopsy) was studied in 337 heart recipients on a cyclosporine-based steroid-sparing regimen. Freedom from CAV for all was 79% at 10 years. Fifty-nine patients (18%) developed CAV at a mean of 6.5 +/- 3 years post-transplant. First year rejections were significantly higher in CAV, mean 2.3 vs. 1.4, P = 0.003, odds ratio (OR) 1.8. Rejection with hemodynamic compromise beyond 1 year post-transplant was associated with CAV, P < 0.001, OR 8.4. There was no significant correlation among human leukocyte antigen DR (HLA DR) mismatch, pacemaker use or homocysteine levels and the development of CAV. Maximum cholesterol and low density lipoprotein (LDL) levels were not significantly different. Neither diabetes nor hypertension was significant predictors of CAV on multivariate logistic regression analysis. In conclusion, frequent and severe rejection episodes may predict pediatric CAV. Neither glucose intolerance nor lipid abnormalities appeared to alter risk for CAV in this population.     

Experience of percutaneous coronary intervention in the management of pediatric cardiac allograft vasculopathy.

In a retrospective study, we examined the procedural success rate and the short-, intermediate-, and long-term outcomes of coronary interventional procedures in children with cardiac allograft vasculopathy. Seven patients underwent 13 interventional procedures: balloon angioplasty alone (n = 3), angioplasty with stenting (n = 9), or angioplasty with brachytherapy (n = 1), with procedural success in all. Two major complications (cardiac arrest) and a single death occurred in the immediate postprocedural period. Five (83%) of the remaining 6 patients developed moderate to severe restenosis, diffuse disease, or progressive vasculopathy; 3 have been retransplanted, 1 died from progressive cardiac allograft vasculopathy, and 1 is awaiting retransplantation, 40 months after the procedure.     

Anti-human leukocyte antigen antibodies are associated with restenosis after percutaneous coronary intervention for cardiac allograft vasculopathy

BACKGROUND: Percutaneous coronary intervention (PCI) to palliate cardiac allograft vasculopathy (CAV) has been associated with high restenosis rates, possibly related to increased inflammation associated with this disease. Whether markers of immunologic rejection are associated with restenosis in this population is unknown. The goal of the study was to determine the predictors of restenosis after PCI for CAV. METHODS: Records were reviewed retrospectively from a single, high-volume cardiac transplant center. Clinical, angiographic, and immunologic data were collected on all patients postorthotopic heart transplantation (OHT) that had subsequent PCI. Restenosis was defined as greater than 50% stenosis at the previous intervention site. RESULTS: PCI was successfully performed on 62 de novo lesions in 40 patients an average of 6.8+/-3.9 years after OHT. Angiographic follow-up data was available for 79%, with an average follow-up of 1.54+/-1.22 years. The 1-year restenosis rate was 49% (64% for balloon percutaneous transluminal coronary angioplasty and 33% for coronary stenting [P=0.09 for difference]). The frequency of immunoglobulin (Ig)G antibody to major histocompatibility complex (MHC) class I antigen was highly associated with risk of restenosis (hazard ratio [HR] 11.33, P=0.01). Greater stenosis severity and smaller target vessel diameter were also predictors of restenosis as in the nontransplant population. CONCLUSIONS: The findings suggest that in patients postPCI for CAV, humoral allo-immunity may contribute to restenosis and that IgG antibodies to MHC class I antigen may help predict the risk of restenosis after PCI in this population.     

Cost-effectiveness analysis of intravascular ultrasound guided percutaneous coronary intervention versus conventional percutaneous coronary intervention

OBJECTIVE: Investigation of the cost-effectiveness of intravascular ultrasound (IVUS) guided percutaneous coronary intervention (PCI) compared to PCI guided by coronary angiography (CAG). METHODS: One hundred and eight men referred for PCI, were randomized to IVUS or CAG guided PCI. After 6 months, the patients were subjected to a study related clinical and invasive follow-up investigation by CAG, IVUS and intracoronary Doppler flow measurements. Incremental costs of IVUS guided procedures and costs of re-interventions were estimated using the Activity Based Costing (ABC) method. RESULTS: Patients randomized to IVUS guided PCI experienced an improved clinical outcome, with lower angina levels than patients in the CAG guided group. The initial cost of performing IVUS guidance was increased due to extra procedure time, IVUS catheters and slightly more balloons and stents, but fewer patients in the IVUS guided group needed re-intervention. Overall, these savings outweighed the initial cost increase. CONCLUSION: Our data suggest that when performing IVUS guided PCI, costs as well as benefits increase. The increased benefits measured as cost savings resulting from less restenosis outweigh the cost increase from performing the IVUS guided PCI as opposed to CAG guided PCI.     

Renal implications of percutaneous coronary intervention

Ongoing advances in catheter-based technologies for the treatment of coronary artery disease have resulted in a steady increase in the volume of percutaneous coronary interventional procedures. This trend is likely to continue well into the next decade, and may be particularly pronounced among a high-risk population of patients. These high-risk patients, whether elderly, diabetic, presenting with preexisting renal insufficiency, congestive heart failure, prior bypass surgery, or diffuse atherosclerotic disease are at increased risk of renal compromise from contrast exposure and catheter manipulations within the aorta. Enhanced physician awareness of the renal implications of percutaneous coronary interventions, in conjunction with careful patient selection, risk assessment, and evolving renal protective strategies will help to minimize the incidence of renal complications and the associated increases in morbidity, mortality, and health care costs.     

Surgical treatment of coronary aneurysm after percutaneous coronary intervention

A 61-year-old man with acute myocardial infarction underwent percutaneous coronary intervention with stent for the left main coronary artery (LMT) and the left anterior descending artery (LAD). Three months later, we recognized the LMT aneurysm complicated with possible thrombus formation, which developed in size during 6 months. In addition, the LAD stent showed significant in-stent stenosis. For the purpose of supplying blood flow to the distal of LAD, and avoiding myocardial infarction due to distal thrombosis possibly originated from LMT aneurysm, we decided to perform surgical operation. On preoperative examination, this patient had an obstruction of the right internal carotid artery. Although the direct repair of LMT aneurysm requires conventional approach with cardiopulmonary bypass, we applied off-pump coronary artery bypass grafting( OPCAB) considering the risk of cerebrovascular event. Consequently, OPCAB was performed in usual fashion [right internal thoracic artery (RITA) -LAD, left internal thoracic artery-left circumflex artery (LITA-LCX)] followed by the ligation of the proximal of LAD and LCX without cardiopulmonary bypass. The patient had a good operative course.     

Cardiac allograft vasculopathy: coronary computed tomography and virtual histology assessment

Introduction

Cardiac allograft vasculopathy remains the leading cause of late morbidity and mortality in heart transplantation. The main diagnostic methods, coronary angiography or intracoronary ultrasound (when angiography is normal), are invasive. Other study methods, such as coronary computed tomography (CT) and virtual histological analysis, have not been widely assessed in this condition.

Objective

The objective of this study was to assess the correlation between data obtained from analysis of virtual histology compared with those obtained from the performance of coronary CT in cardiac transplant recipients.

Materials and Methods

During the same admission we performed coronary angiography and intravascular ultrasound with virtual histological analysis (automatic pull-back in anterior descending artery and one additional vessel if the former was normal) as well as coronary CT.

Results

The study included 10 patients. Virtual histology was done in segments with intimal thickening >0.5 mm, defining 2 groups of plaque, those with an inflammatory component (necrotic core >30% and calcium) versus those without it defined as the combination of both being <30%. A calcium component of the inflammatory plaque allowed coronary CT detection.

Conclusions

The detection of inflammatory plaque in graft vessel disease can be based on an initial noninvasive method, such as coronary CT, although confirmation requires further study.     

Infected coronary artery pseudoaneurysm after repeated percutaneous coronary intervention

Coronary stent infection is exceedingly rare, with only 23 reported cases. We present a patient with an everolimus-coated stent infection that led to an infected pseudoaneurysm in the left anterior descending artery. Medical therapy failed and the patient underwent emergent surgical intervention; however, he died of multiorgan failure after the operation.     

Aortic root abscess after percutaneous coronary intervention

A 68-year-old man, who had undergone percutaneous coronary intervention for right coronary disease 2 weeks earlier, was admitted to our hospital for investigation of a fever. Blood culture and echocardiography revealed isolated aortic valve infective endocarditis. He was treated with antibiotics for more than 1 week, but echocardiography showed an aortic root abscess with severe aortic regurgitation. Thus, we performed aortic root replacement using an artificial Freestyle stentless bioprosthesis valve. The patient had an uneventful postoperative course and antibiotic treatment was continued for a further 8 weeks.     

Survival difference between coronary bypass surgery and percutaneous coronary intervention

Abstract

Objectives. To assess whether the previously observed lower death rate with coronary artery bypass surgery compared with percutaneous coronary intervention in subsets of patients with coronary artery disease persists in more recent years. Design. Retrospective study from Feiring Heart Clinic database of survival in 17739 patients followed for 5 years after coronary revascularization. The cohorts treated in 1999–2005 and 2006–2011 were compared using Cox regression and propensity score analyses. Results. Cox regression and propensity score analyses revealed no difference in survival in either time period in one- and two-vessel diseases. In three-vessel disease, the hazard ratios between bypass surgery and percutaneous intervention were 0.62 (95% confidence interval [CI]: 0.53–0.71, p <0.001) and 0.59 (95% CI: 0.47–0.73, p < 0.001), respectively, in the two time periods, indicating persistent higher survival with bypass surgery. Conclusions. The previously observed lower death rate of coronary artery bypass surgery compared with percutaneous intervention in patients with three-vessel disease is persistent in more recent years and indicates that bypass surgery still should be the standard treatment for these patients.     

Status of percutaneous coronary intervention and coronary artery bypass.

At present a rapid and profound change in myocardial revascularization has evolved from the work of Gruentzig. The recent technological advances have been so fast paced that there has not been ample time to fully assess each new facet of technology and pharmaceutics before another arrives. The interface between percutaneous intervention (PCI) and coronary artery bypass (CAB) is not well defined as previously so that continental, national and regional differences exist. The progress in PCI from balloon angioplasty to drug eluting stents has seen a progressive decline in restenosis and reintervention but relief of symptoms has not equaled that attained with CAB. Survival benefit for CAB over PCI has not been demonstrated in the many randomized clinical trials which are limited by selection of only 5-12% of potential patients so that higher risk patients and those with more extensive and complex coronary disease are excluded. These excluded patients are included in the registries where survival benefit for CAB over PCI is clearly evident. Situations less amenable to PCI include: left main disease; three vessel disease; vessels that are smaller, diffusely diseased or with distal lesions which are frequently associated with diabetes; ostial and bifurcation lesions; and coronary arteries that are tortuous, calcified or with very long lesions. It is in these situations that PCI does not provide revascularization equivalent to CAB. Surgeons must appreciate the success of PCI, acknowledge their reduced role in revascularization and strive to provide the best operation possible when the clinical situation demands it.     

Combined coronary intervention in heart-transplant patient with rapidly accelerated cardiac allograft vasculopathy

A 46-year-old man accepted for heart transplantation due to persistent cardiac failure from dilated cardiomyopathy underwent a transplant in Germany on July 13, 1995. The donor heart was suspected of coronary artery disease at explantation, but he could wait no longer because of his rapidly deteriorating hemodynamics. Postoperative coronary angiography revealed 25% stenosis of the left descending artery. He showed several episodes of minimal or moderate rejection postoperatively, and coronary angiography 15 months postoperatively showed rapidly accelerated cardiac allograft vasculopathy demonstrating triple vessel disease with multiple lesions. Percutaneous transluminal coronary angioplasty was successful on 2 coronary vessels, but immediately recurrent stenosis and new lesions involving the left main trunk occurred 6 weeks thereafter. Since he was financially unable to afford a second heart transplantation, quadruple coronary artery bypass grafting was conducted October 25, 1996. A biventricular assist device was used when he could not be weaned from cardiopulmonary bypass. He died of multiple organ failure 3 days after surgery.     

Percutaneous coronary intervention versus medical therapy for coronary allograft vasculopathy. One center's experience.

BACKGROUND: Coronary allograft vasculopathy, a rapidly progressive form of atherosclerosis, remains the limiting factor in the long-term survival of heart transplant recipients. Some centers have attempted percutaneous coronary intervention to slow the disease process and thereby reduce mortality in these patients, but long-term follow-up data are scarce. We compared clinical outcomes in heart transplant recipients with coronary allograft vasculopathy who were treated either with percutaneous coronary intervention or with aggressive medical therapy alone. METHODS: A retrospective analysis of all heart transplant recipients at our institution who underwent surveillance coronary angiography for coronary allograft vasculopathy between 1995 and 2000 was performed. Patients with coronary allograft vasculopathy were stratified according to whether they received medical therapy or percutaneous coronary intervention. Baseline demographics, results of re-vascularization procedures and outcomes were analyzed. RESULTS: From 1995 to 2000, 301 patients underwent 602 coronary angiograms. Of the 79 patients who had angiographic evidence of coronary allograft vasculopathy, 53 were treated with aggressive medical therapy, while 26 underwent percutaneous coronary intervention in addition to aggressive medical therapy. At baseline, patients treated with aggressive medical therapy tended to be younger (54.6 +/- 13.8 years) than patients treated with percutaneous coronary intervention (62.6 +/- 7.6 years; p = 0.0079). Ejection fraction at time of diagnosis of coronary allograft vasculopathy was similar for both groups (medical therapy group, 44.4 +/- 13.4% vs percutaneous coronary intervention group, 47.2 +/- 12.7%; p = 0.38). In our cohort, heart transplant recipients with coronary allograft vasculopathy demonstrated greater mortality than heart transplant recipients without coronary allograft vasculopathy (p = 0.016). Patients who underwent percutaneous coronary intervention had a 60% re-stenosis rate at 6 months if they were treated with coronary angioplasty and an 18% re-stenosis rate if they received a coronary stent. Kaplan-Meier analysis showed no significant difference in survival in either treatment group at 1 year (80% for medical therapy group vs 95% for percutaneous coronary intervention group) or 3 years (68% for medical therapy group vs 79% for percutaneous coronary intervention group) after the angiographic diagnosis of coronary allograft vasculopathy. CONCLUSION: In this non-randomized trial, heart transplant recipients with coronary allograft vasculopathy were less likely to survive than patients without it. In addition, we found no statistical difference in mortality in heart transplant recipients with coronary allograft vasculopathy, regardless of whether they received percutaneous coronary intervention or aggressive medical therapy alone.     

Angiogenesis occurs within the intimal proliferation that characterizes transplant coronary artery vasculopathy.

BACKGROUND: Vascular remodeling is central to the development of transplant coronary artery vasculopathy (CAV). For remodeling to occur, a sustained blood and nutrient supply is essential. Here we report on the presence of angiogenesis within the neointima of coronary arteries from cardiac transplant recipients. METHODS: Coronary arteries from 57 cardiac transplant recipients with CAV were analyzed. Immunocytochemistry with antibodies raised against endothelial cells (CD31, CD34, and vWF), vascular smooth muscle cells (SmA), and activated endothelial cells (MHC 2, P-SEL, E-SEL, and VCAM-1) was performed. RESULTS: A total of 89% of patients had significant angiogenesis. These vessels appeared as endothelial lined channels and were present in a concentric circumferential pattern within the mid portion of the neointima. These new vessels were present at an interface between an area of intimal hyperplasia and below an area of fibrous regeneration. These 2 distinct zones were present in 64% of the cases, and were clearly demonstrated with an elastic van Gieson (EVG) stain and are distinctly different from that seen in native atherosclerosis. Endothelial activation markers were strongly expressed by the endothelial cells lining new vessels, suggesting that they are functional and may aid in the recruitment of inflammatory cells. CONCLUSIONS: These data suggest that angiogenesis is present within the intima of CAV lesions and may contribute to the continued obliteration of the vessel lumen. The vessels appear to originate in the intima and may represent the location of the donor endothelium before transplantation. Inhibition of endothelial damage may provide therapeutic options to prevent the progression of CAV.     

急性心肌梗死PCI术后患者基于5A模式的早期心脏康复护理

目的探讨基于5A模式的早期心脏康复护理在急性心肌梗死(AMI)行经皮冠状动脉介入术(PCI)患者中的应用效果。方法按住院时间先后将诊断为AMI并急诊行PCI治疗的88例患者分为对照组43例、观察组45例。对照组给予常规治疗和护理;观察组在常规治疗和护理的基础上,给予基于5A模式的早期心脏康复护理干预。比较两组干预后2周和1个月的生活自理能力、康复锻炼依从性,以及两组干预后1个月左心室射血分数值、6 min步行距离、冠心病自我管理能力及术后心血管不良事件发生率。结果干预后观察组左心室射血分数值、6 min步行距离、生活自理能力得分,术后康复锻炼依从性、冠心病自我管理能力得分显著高于对照组(P<0.05,P<0.01);观察组术后心原性休克、冠状动脉再狭窄、心律失常、心力衰竭发生率与对照组比较差异无统计学差异(均P>0.05),但心绞痛发生率显著降低(P<0.05)。结论基于5A模式的早期心脏康复护理可提高术后患者康复锻炼依从性,改善患者心功能,增强运动耐量,提高自理能力,并提高冠心病患者自我管理能力。     

Coronary artery bypass grafting after percutaneous coronary intervention

Following percutaneous intervention (PCI), restenosis, progression of disease and multi-vessel involvement may require further intervention in the form of surgical revascularization. Patients with coronary artery bypass grafting (CABG) done after PCI were evaluated to find out the reason for the need of surgical revascularization. Over a period of 12 months, 610 patients underwent CABG. Out of them, 34 patients had previous PCI/stenting. Coronary risk factors including hypertension in 85%, diabetes mellitus in 60%, dyslipidemia in 60%, tobacco use in 50% and a positive family history was present in 53% of the patients. All patients were symptomatic. Multi-vessel disease was present in 67% and single vessel in 4.7%. The extent of disease and stenosis of stents were responsible for reintervention. Careful selection of patients is required in presence of multiple risk factors for coronary artery disease to provide maximum benefit by either PCI or CABG.     

Successful percutaneous coronary intervention significantly improves coronary sinus blood flow as assessed by transthoracic echocardiography

Background

Transthoracic echocardiography (TTE) has been used to assess coronary sinus blood flow (CSBF), which reflects total coronary arterial blood flow. Successful angioplasty is expected to improve coronary arterial blood flow. Changes in CSBF after percutaneous coronary intervention (PCI), as assessed by TTE, have not been systematically evaluated.

Hypothesis

TTE can be utilized to reflect increased CSBF after a successful, clinically indicated PCI.

Methods

The study cohort included 31 patients (18 females, 62 ± 11 years old) referred for diagnostic cardiac catheterization for suspected coronary artery disease and possible PCI, when clinically indicated. All performed PCIs were successful, with good angiographic outcome. CSBF per cardiac cycle (mL/beat) was measured using transthoracic two-dimensional and Doppler flow imaging as the product of coronary sinus (CS) area and CS flow time–velocity integral. CSBF per minute (mL/min) was calculated as the product of heart rate and CSBF per cardiac cycle. In each patient, CSBF was assessed prospectively, before and after cardiac catheterization with and without clinically indicated PCI. Within- and between-group differences in CSBF before and after PCI were assessed using repeated measures analysis of variance.

Results

Technically adequate CSBF measurements were obtained in 24 patients (77%). In patients who did not undergo PCI, there was no significant change in CSBF (278.1 ± 344.1 versus 342.7 ± 248.5, p = 0.36). By contrast, among patients who underwent PCI, CSBF increased significantly (254.3 ± 194.7 versus 618.3 ± 358.5 mL/min, p < 0.01, p-interaction = 0.03). Other hemodynamic and echocardiographic parameters did not change significantly before and after cardiac catheterization in either treatment group.

Conclusions

Transthoracic echocardiographic assessment can be employed to document CSBF changes after angioplasty. Future studies are needed to explore the clinical utility of this noninvasive metric.