Long-term outcome of cardiac allograft vasculopathy: Importance of the International Society for Heart and Lung Transplantation angiographic grading scale

• Published in: The Journal of heart and lung transplantation Vol. 38; no. 11; pp. 1189 - 1196
• Main Authors: Van Keer, Jan M., Van Aelst, Lucas N.L., Rega, Filip, Droogne, Walter, Voros, Gabor, Meyns, Bart, Vanhaecke, Johan, Emonds, Marie-Paule, Janssens, Stefan, Naesens, Maarten, Van Cleemput, Johan
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-11-2019
• Subjects: Adult; angiography; cardiac allograft vasculopathy; CAV; Cohort Studies; Coronary Angiography; Coronary Artery Disease - classification; Coronary Artery Disease - diagnostic imaging; Coronary Artery Disease - etiology; Female; Follow-Up Studies; heart transplantation; Heart Transplantation - adverse effects; Humans; International Agencies; Lung Transplantation; Male; Middle Aged; outcome; Postoperative Complications - classification; Postoperative Complications - diagnostic imaging; Postoperative Complications - etiology; risk factors; Societies, Medical; Time Factors; Treatment Outcome; cardiac allograft vasculopathy; CAV; risk factors; heart transplantation; angiography; outcome
• ISSN: 1053-2498; 1557-3117
• DOI: 10.1016/j.healun.2019.08.005

Cardiac allograft vasculopathy (CAV) is a major complication limiting long-term survival after heart transplantation (HTx). However, long-term outcome data of HTx recipients with detailed information on angiographic severity are scarce.
The study included 501 HTx recipients with angiographic follow-up up to 20 years post-transplant. All coronary angiograms were classified according to the International Society for Heart and Lung Transplantation (ISHLT) grading scale.
CAV prevalence increased over time after transplantation, reaching 10% at 1 year, 44% at 10 years, and 59% at 20 years. Older donor age (hazard ratio [HR] 1.38 per 10 years, 1.20–1.59, p < 0.001), male donor sex (HR 1.86, 1.31–2.64, p < 0.001), stroke as donor cause of death (HR 1.47, 1.04–2.09, p = 0.03), recipient pre-transplant hemodynamic instability (HR 1.79, 1.15–2.77, p = 0.01), post-transplant smoking (HR 1.59, 1.06–2.39, p = 0.03), and first-year treated rejection episodes (HR 1.49, 1.01–2.20, p = 0.046) were independent risk factors for CAV. Baseline anti-metabolite drug use (HR 0.57, 0.34–0.95, p = 0.03) and more recent transplant date (HR 0.78 per 10 years, 0.62–0.99, p = 0.04) were protective factors. Compared with patients without CAV, the HR for death or retransplantation was 1.22 (0.85–1.76, p = 0.28) for CAV 1, 1.86 (1.08–3.22, p = 0.03) for CAV 2, and 5.71 (3.64–8.94, p < 0.001) for CAV 3.
CAV is highly prevalent in HTx recipients and is explained by immunologic and non-immunologic factors. Higher ISHLT CAV grades are independently associated with worse graft survival.