Functional Assessment and Graft Loss in Cardiac Allograft Vasculopathy

Jul 27, 2015
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Authors:
Kindel SJ, Law YM, Chin C, et al.
Citation:
Improved Detection of Cardiac Allograft Vasculopathy: A Multi-Institutional Analysis of Functional Parameters in Pediatric Heart Transplant Recipients. J Am Coll Cardiol 2015;66:547-557.
Summary By:
Monica M. Colvin, MD

Study Questions:

Can assessment of systolic and diastolic function identify patients with cardiac allograft vasculopathy (CAV) who are at risk for death or retransplantation?

Methods:

This was a retrospective analysis of the Pediatric Heart Transplant Study (PHTS). Angiographic data were reviewed and graded according to the International Society for Heart and Lung Transplantation CAV guidelines. Ejection fraction (EF) was used for evaluation of systolic function, and right atrial pressure (RAP) or pulmonary capillary wedge pressure (PCWP) was used for diastolic performance. Both pediatric and adult thresholds for hemodynamics were assessed. Graft survival based on the degree of CAV and functional alteration was assessed.

Results:

This analysis included 3,120 pediatric heart transplant recipients between 1993 and 2009, and 8,122 angiograms. Angiographic CAV was present in 10.4% of angiograms, of which CAV-1 was most prevalent, occurring in 7.8%. The presence of any CAV at 1, 5, and 10 years post-transplant occurred in 2.3%, 13.9%, and 27.5%, respectively. Graft survival at 1 and 5 years was 82%/67%, 65%/45%, and 35%/25% in CAV-1, CAV-2, and CAV-3, respectively. Left ventricular EF was significantly correlated to graft loss (death or retransplant), and recipients with EF <45% and any degree of CAV had significantly worse graft survival than those with EF >45%. When hemodynamics were considered, an RAP >13 mm Hg was associated with increased graft loss at all degrees of CAV. This effect was enhanced by RAP >20 mm Hg. PCWP ≥16 mm Hg was associated with increased graft loss, and those with PCWP >25 mm Hg had very early graft loss and significantly worse survival than those with PCWP ≤15 mm Hg.

Conclusions:

The authors concluded that the presence of graft dysfunction is associated with increased risk of graft loss in pediatric heart transplant recipients with CAV.

Perspective:

Evaluation of systolic and diastolic function in heart transplant recipients provides additional prognostic information to angiographic data, and should be considered as part of surveillance for CAV.

Keywords: Allografts, Atrial Pressure, Graft Survival, Heart Failure, Heart Failure, Diastolic, Heart Failure, Systolic, Heart Transplantation, Pediatrics, Pulmonary Wedge Pressure, Reoperation


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