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Amancherla K, Schlendorf KH, Chow N, Sheng Q, Freedman JE, Rathmell JC. Single-cell RNA-sequencing identifies unique cell-specific gene expression profiles in high-grade cardiac allograft vasculopathy. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.07.10.602989. [PMID: 39026730 PMCID: PMC11257508 DOI: 10.1101/2024.07.10.602989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
Background Cardiac allograft vasculopathy (CAV), a diffuse thickening of the intima of the coronary arteries and microvasculature, is the leading cause of late graft failure and mortality after heart transplantation (HT). Diagnosis involves invasive coronary angiography, which carries substantial risk, and minimally-invasive approaches to CAV diagnosis are urgently needed. Using single-cell RNA-sequencing in peripheral blood mononuclear cells (PBMCs), we sought to identify cell-specific gene expression profiles in CAV. Methods Whole blood was collected from 22 HT recipients with angiographically-confirmed CAV and 18 HT recipients without CAV. PBMCs were isolated and subjected to single-cell RNA-sequencing using a 10X Genomics microfluidic platform. Downstream analyses focused on differential expression of genes, cell compositional changes, and T cell receptor repertoire analyses. Results Across 40 PBMC samples, we isolated 134,984 cells spanning 8 major clusters and 31 subclusters of cell types. Compositional analyses showed subtle, but significant increases in CD4+ T central memory cells, and CD14+ and CD16+ monocytes in high-grade CAV (CAV-2 and CAV-3) as compared to low-grade or absent CAV. After adjusting for age, gender, and prednisone use, 745 genes were differentially expressed in a cell-specific manner in high-grade CAV. Weighted gene co-expression network analyses showed enrichment for putative pathways involved in inflammation and angiogenesis. There were no significant differences in T cell clonality or diversity with increasing CAV severity. Conclusions Unbiased whole transcriptomic analyses at single-cell resolution identify unique, cell-specific gene expression patterns in CAV, suggesting the potential utility of peripheral gene expression biomarkers in diagnosing CAV.
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Pighi M, Tomai F, Fezzi S, Pesarini G, Petrolini A, Spedicato L, Tarantini G, Ferlini M, Calabrò P, Loi B, Ferrero V, Forero MNT, Daemen J, Ribichini F. Safety and efficacy of everolimus-eluting bioresorbable vascular scaffold for cardiac allograft vasculopathy (CART). Clin Res Cardiol 2024; 113:1017-1029. [PMID: 38170246 DOI: 10.1007/s00392-023-02351-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/29/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is still the main drawback of heart transplantation (HTx) and percutaneous coronary intervention (PCI) is a palliative measure because of the high incidence of failure. OBJECTIVE This study aimed to investigate the safety and efficacy of bioresorbable scaffolds (BRSs) as potential novel therapeutic tool for the treatment of coronary stenoses in CAV. METHODS This is a multicenter, single-arm, prospective, open-label study (CART, NCT02377648), that included patients affected by advanced CAV treated with PCI and second-generation ABSORB BRS (Abbott Vascular). The primary endpoint was the incidence of 12-month angiographic in-segment scaffold restenosis (ISSR). Secondary endpoints were the incidence of major adverse cardiac events (MACEs) at 12- and 36-month follow-up and the incidence of ISSR at 36 months. A paired intracoronary imaging analysis at baseline and follow-up was also performed. RESULTS Between 2015 and 2017 35 HTx patients were enrolled and treated for 44 coronary lesions with 51 BRSs. The primary endpoint occurred in 13.5% of the lesions (5/37), with a cumulative ISSR rate up to 3 years of 16.2% (6/37). Angiographic lumen loss was 0.40 ± 0.62 mm at 12 months and 0.53 ± 0.57 mm at 36 months. Overall survival rate was 91.4% and 74.3%, and MACEs incidence 14.2% and 31.4% at 12 and 36 months, respectively. At the paired intracoronary imaging analysis, a significant increase of the vessel external elastic membrane area in the treated segment and some progression of CAV proximally to the BRS were detected. CONCLUSIONS BRS-based PCI for the treatment of CAV is feasible and safe, with an ISSR incidence similar to what reported in retrospective studies with drug-eluting stents.
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Affiliation(s)
- Michele Pighi
- Division of Cardiology, Department of Medicine, University of Verona, Piazzale Aristide Stefani, 1, 37126, Verona, Italy
| | - Fabrizio Tomai
- Department of Cardiovascular Sciences, European Hospital, Rome, Italy
| | - Simone Fezzi
- Division of Cardiology, Department of Medicine, University of Verona, Piazzale Aristide Stefani, 1, 37126, Verona, Italy
| | - Gabriele Pesarini
- Division of Cardiology, Department of Medicine, University of Verona, Piazzale Aristide Stefani, 1, 37126, Verona, Italy.
| | | | - Leonardo Spedicato
- Department of Cardiovascular Sciences, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Marco Ferlini
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
- Division of Clinical Cardiology, Sant'Anna e San Sebastiano Hospital, Caserta, Italy
| | - Bruno Loi
- Division of Cardiology, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Valeria Ferrero
- Division of Cardiology, Department of Medicine, University of Verona, Piazzale Aristide Stefani, 1, 37126, Verona, Italy
| | | | - Joost Daemen
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Piazzale Aristide Stefani, 1, 37126, Verona, Italy
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Moayedi Y, Rodenas-Alesina E, Somerset E, Fan CPS, Henricksen E, Aleksova N, Billia F, Chih S, Ross HJ, Teuteberg JJ. Enhancing the Prediction of Cardiac Allograft Vasculopathy Using Intravascular Ultrasound and Machine Learning: A Proof of Concept. Circ Heart Fail 2024; 17:e011306. [PMID: 38314558 DOI: 10.1161/circheartfailure.123.011306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/08/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is the leading cause of late graft dysfunction in heart transplantation. Building on previous unsupervised learning models, we sought to identify CAV clusters using serial maximal intimal thickness and baseline clinical risk factors to predict the development of early CAV. METHODS This is a single-center retrospective study including adult heart transplantation recipients. A latent class mixed-effects model was used to identify patient clusters with similar trajectories of maximal intimal thickness posttransplant and pretransplant covariates associated with each cluster. RESULTS Among 186 heart transplantation recipients, we identified 4 patient phenotypes: very low, low, moderate, and high risk. The 5-year risk (95% CI) of the International Society for Heart and Lung Transplantation-defined CAV in the high, moderate, low, and very low risk groups was 49.1% (35.2%-68.5%), 23.4% (13.3%-41.2%), 5.0% (1.3%-19.6%), and 0%, respectively. Only patients in the moderate to high risk cluster developed the International Society for Heart and Lung Transplantation CAV 2-3 at 5 years (P=0.02). Of the 4 groups, the low risk group had significantly younger female recipients, shorter ischemic time, and younger female donors compared with the high risk group. CONCLUSIONS We identified 4 clusters characterized by distinct maximal intimal thickness trajectories. These clusters were shown to discriminate against the development of angiographic CAV. This approach allows for the personalization of surveillance and CAV-directed treatment before the development of angiographically apparent disease.
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Affiliation(s)
- Yasbanoo Moayedi
- Ted Rogers Centre of Excellence in Heart Research (Y.M., E.R.-A., N.A., F.B., H.J.R.), Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada (Y.M., N.A., F.B., H.J.R.)
| | - Eduard Rodenas-Alesina
- Ted Rogers Centre of Excellence in Heart Research (Y.M., E.R.-A., N.A., F.B., H.J.R.), Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Emily Somerset
- Ted Rogers Computational Program, Centre of Excellence in Heart Function (E.S., C.P.S.F.), Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Chun Po S Fan
- Ted Rogers Computational Program, Centre of Excellence in Heart Function (E.S., C.P.S.F.), Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | | | - Natasha Aleksova
- Ted Rogers Centre of Excellence in Heart Research (Y.M., E.R.-A., N.A., F.B., H.J.R.), Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada (Y.M., N.A., F.B., H.J.R.)
| | - Filio Billia
- Ted Rogers Centre of Excellence in Heart Research (Y.M., E.R.-A., N.A., F.B., H.J.R.), Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada (Y.M., N.A., F.B., H.J.R.)
| | - Sharon Chih
- Ottawa Heart Institute, University of Ottawa, ON, Canada (S.C.)
| | - Heather J Ross
- Ted Rogers Centre of Excellence in Heart Research (Y.M., E.R.-A., N.A., F.B., H.J.R.), Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada (Y.M., N.A., F.B., H.J.R.)
| | - Jeffrey J Teuteberg
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, Department of Medicine, Stanford University, CA (J.J.T.)
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Rodenas-Alesina E, Aleksova N, Stubbs M, Foroutan F, Kozuszko S, Posada JD, McDonald M, Moayedi Y, Ross H, Dipchand A. Cardiac allograft vasculopathy and survival in pediatric heart transplant recipients transitioned to adult care. J Heart Lung Transplant 2024; 43:229-237. [PMID: 37704160 DOI: 10.1016/j.healun.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is an important cause of mortality after pediatric heart transplantation (HT) but there is a paucity of data regarding its incidence and impact on survival in pediatric recipients transitioned to adult care. METHODS We conducted a retrospective review of consecutive pediatric HT patients from 1989 to 2017 at the Hospital for Sick Children who transitioned to adult care at ≥18 years at Toronto General Hospital. We evaluated the incidence of International Society of Heart and Lung Transplantation CAV grade ≥1 using competing risk models. We assessed the association between all-cause mortality and CAV using Cox proportional hazards and used Kaplan Meier methods to evaluate all-cause mortality stratified by CAV and transplant era (1989-2001, 2002-2017). RESULTS Ninety-six patients were transitioned to adult care by January 2022, of which 53 underwent repeat coronary angiography as adults. CAV was newly diagnosed in 49% patients after transition to adult care. The overall incidence of CAV was 3.9 cases per 100 person-years. There was no difference in the adjusted incidence of CAV according to transplant era (subdistribution hazard ratios = 1.17, 95% confidence interval (CI) 0.54-2.66). CAV was associated with a higher risk of death in the early era (hazard ratio (HR) 10.29, 95% CI 2.16-49.96), but not in the recent era (HR 1.61, 95% 0.35-7.47). CONCLUSIONS There is a role for continued CAV surveillance after the transition to adult care. The implications of diagnosing CAV after the transition to adult care require further study, particularly because the risk of death in pediatric HT recipients diagnosed with CAV in the more recent era may be attenuated compared to the earlier HT era.
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Affiliation(s)
| | - Natasha Aleksova
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Women's College Hospital, Toronto, Ontario, Canada.
| | - Michael Stubbs
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Farid Foroutan
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Stella Kozuszko
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Juan Duero Posada
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Michael McDonald
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Yasbanoo Moayedi
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Heather Ross
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Anne Dipchand
- Hospital for Sick Children, Toronto, Ontario, Canada
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Bora N, Balogh O, Ferenci T, Piroth Z. Functional Assessment of Long-Term Microvascular Cardiac Allograft Vasculopathy. J Pers Med 2023; 13:1686. [PMID: 38138913 PMCID: PMC10744790 DOI: 10.3390/jpm13121686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/20/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is a leading cause of death and retransplantation following heart transplantation (HTX). Surveillance angiography performed yearly is indicated for the early detection of the disease, but it remains of limited sensitivity. METHODS We performed bolus thermodilution-based coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) and fractional flow reserve (FFR) measurements in HTX patients undergoing yearly surveillance coronary angiography without overt CAV. RESULTS In total, 27 HTX patients were included who had 52 CFR, IMR, and FFR measurements at a mean of 43 months after HTX. Only five measurements were performed in the first year. CFR decreased significantly by 0.13 every year (p = 0.04) and IMR tended to increase by 0.98 every year (p = 0.051), whereas FFR did not change (p = 0.161) and remained well above 0.80 over time. After one year, CFR decreased significantly (p = 0.022) and IMR increased significantly (p = 0.015), whereas FFR remained unchanged (p = 0.72). CONCLUSIONS The functional status of the epicardial coronary arteries of transplanted hearts did not deteriorate over time. On the contrary, a significant decrease in CFR was noted. In view of the increasing IMR, this is caused by the deterioration of the function of microvasculature. CFR and IMR measurements may provide an early opportunity to diagnose CAV.
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Affiliation(s)
- Noemi Bora
- Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary; (N.B.); (O.B.)
- Károly Rácz Doctoral School of Clinical Medicine, Semmelweis University, 1085 Budapest, Hungary
| | - Orsolya Balogh
- Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary; (N.B.); (O.B.)
| | - Tamás Ferenci
- Physiological Controls Group, John von Neumann Faculty of Informatics, Obuda University, 1034 Budapest, Hungary;
| | - Zsolt Piroth
- Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary; (N.B.); (O.B.)
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6
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Chang A, Martin KA, Colvin M, Bellumkonda L. Role of ascorbic acid in cardiac allograft vasculopathy. Clin Transplant 2023; 37:e15153. [PMID: 37792313 DOI: 10.1111/ctr.15153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/04/2023] [Accepted: 09/22/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE OF THE REVIEW Cardiac allograft vasculopathy (CAV) is a progressive fibroproliferative disease which occurs after heart transplantation and is associated with significant long-term morbidity and mortality. Currently available strategies including statins, mammalian target of rapamycin (mTOR) inhibitors, and revascularization, have limited overall effectiveness in treating this pathology once the disease process is established. mTOR inhibitors, while effective when used early in the disease process, are not well tolerated, and hence not routinely used in post-transplant care. RECENT DATA Recent work on rodent models have given us a novel mechanistic understanding of effects of ascorbic acid in preventing CAV. TET methyl cytosine dioxygenase2 (TET2) reduces vascular smooth muscle cell (VSMC) apoptosis and intimal thickening. TET2 is repressed by interferon γ (IFNγ) in the setting of CAV. Ascorbic acid has been shown to promote TET2 activity and attenuate allograft vasculopathy in animal models and CAV progression in a small clinical trial. SUMMARY CAV remains a challenging disease process and needs better preventative strategies. Ascorbic acid improves endothelial dysfunction, reduces reactive oxygen species, and prevents development of intimal hyperplasia by preventing smooth muscle cell apoptosis and hyperproliferation. Further large-scale randomized control studies of ascorbic acid are needed to establish the role in routine post-transplant management.
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Affiliation(s)
- Alyssa Chang
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kathleen A Martin
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Monica Colvin
- Division of Cardiology, Department of Medicine, Yale University, New Haven, Connecticut, USA
| | - Lavanya Bellumkonda
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Takahashi T, Kobayashi Y, Saeed O, Vukelic S, Jorde UP, Shin JJ, Patel SR. Early optical coherence tomography evaluation of donor-transmitted atherosclerosis and cardiac allograft vasculopathy: insights from a prospective, single-center study. J Heart Lung Transplant 2023; 42:1678-1687. [PMID: 37454771 DOI: 10.1016/j.healun.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/10/2023] [Accepted: 07/12/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND The impact of donor transmitted atherosclerosis as assessed by intravascular ultrasound on development and progression of cardiac allograft vasculopathy (CAV) after heart transplantation (HT) remains poorly defined in contemporary practice. In this exploratory analysis, we sought to assess the prognostic role of early qualitative assessment of donor artery morphology using optical coherence tomography (OCT) as a more sensitive imaging modality. METHODS HT recipients were prospectively enrolled for baseline OCT imaging of the left anterior descending coronary artery. OCT findings were classified as normal, homogeneous intimal thickening, and advanced plaque characteristics. The endpoint was a composite of cardiac death, myocardial infarction, or new angiographically detectable CAV stratified by the International Society of Heart and Lung Transplantation criteria up to 4 years of follow-up. RESULTS A total of 35 patients underwent baseline OCT of whom 51.4% had normal OCT, 14.3% had homogenous plaque, and 34.3% had advanced characteristics. There were no significant differences in baseline demographics between patients with and without normal morphology. During a mean follow-up of 3.3 ± 0.4 years, the endpoint occurred in 11 patients including 1 death, 7 CAV1, 3 CAV2, and 1 CAV3. Kaplan-Meier analysis revealed a significantly higher event rate in patients with advanced characteristics (log-rank p = 0.010). In multivariate analysis, OCT-based plaque morphology was an independent predictor of clinical events (adjusted hazard ratio 4.57, 95% confidence interval 1.50-13.92, p = 0.008) while maximal intimal thickness ≥0.5 mm was not. CONCLUSIONS Early qualitative OCT assessment of donor coronary artery morphology appears to be a reliable marker for predicting future cardiovascular events in HT recipients. Our findings warrant more careful study in a larger cohort.
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Affiliation(s)
- Tatsunori Takahashi
- Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Yuhei Kobayashi
- New York-Presbyterian Brooklyn Methodist Hospital, Weill Cornell Medical College, Brooklyn, New York.
| | - Omar Saeed
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Sasha Vukelic
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Ulrich P Jorde
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Jooyoung Julia Shin
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Snehal R Patel
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
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Iwańczyk S, Woźniak P, Smukowska-Gorynia A, Araszkiewicz A, Nowak A, Jankowski M, Konwerska A, Urbanowicz T, Lesiak M. Microcirculatory Disease in Patients after Heart Transplantation. J Clin Med 2023; 12:jcm12113838. [PMID: 37298033 DOI: 10.3390/jcm12113838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 05/25/2023] [Accepted: 06/02/2023] [Indexed: 06/12/2023] Open
Abstract
Although the treatment and prognosis of patients after heart transplantation have significantly improved, late graft dysfunction remains a critical problem. Two main subtypes of late graft dysfunction are currently described: acute allograft rejection and cardiac allograft vasculopathy, and microvascular dysfunction appears to be the first stage of both. Studies revealed that coronary microcirculation dysfunction, assessed by invasive methods in the early post-transplant period, correlates with a higher risk of late graft dysfunction and death during long-term follow-up. The index of microcirculatory resistance, measured early after heart transplantation, might identify the patients at higher risk of acute cellular rejection and major adverse cardiovascular events. It may also allow optimization and enhancement of post-transplantation management. Moreover, cardiac allograft vasculopathy is an independent prognostic factor for transplant rejection and survival rate. The studies showed that the index of microcirculatory resistance correlates with anatomic changes and reflects the deteriorating physiology of the epicardial arteries. In conclusion, invasive assessment of the coronary microcirculation, including the measurement of the microcirculatory resistance index, is a promising approach to predict graft dysfunction, especially the acute allograft rejection subtype, during the first year after heart transplantation. However, further advanced studies are needed to fully grasp the importance of microcirculatory dysfunction in patients after heart transplantation.
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Affiliation(s)
- Sylwia Iwańczyk
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Patrycja Woźniak
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Anna Smukowska-Gorynia
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | | | - Alicja Nowak
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Maurycy Jankowski
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, 60-701 Poznań, Poland
- Department of Histology and Embryology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Aneta Konwerska
- Department of Histology and Embryology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Tomasz Urbanowicz
- Cardiac Surgery and Transplantology Department, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Maciej Lesiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
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Civieri G, Masiero G, Osto E, Gambino A, Angelini A, Fraiese A, Fedrigo M, Toscano G, Bottio T, Perazzolo Marra M, Iliceto S, Gerosa G, Tona F. Coronary Collateral Circulation: A New Predictor of Mortality in Heart Transplant Recipients With Allograft Vasculopathy. Transplant Direct 2023; 9:e1470. [PMID: 37090121 PMCID: PMC10118324 DOI: 10.1097/txd.0000000000001470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 04/25/2023] Open
Abstract
Coronary collateral arteries (CCAs) are anastomotic channels between vessels; although beneficial in atherosclerosis, their role in heart transplantation (HT) recipients is underinvestigated. CCAs initially develop as microcirculation and cardiac allograft vasculopathy (CAV), promoting immune-dependent proliferative angiogenic response, and play a role in their development. In our hypothesis, ischemia induced by coronary microvascular dysfunction (CMD) triggers the development of CCAs, which are, in turn, less functional as affected by CAV themselves. Methods One hundred twenty-one patients receiving HT at our institution were retrospectively evaluated and were included if transthoracic echocardiography with coronary flow velocity reserve (CFVR) assessment and coronary angiography were performed. CMD was defined as CFVR of ≤2.5. Patients with CAV were enrolled, and their angiograms were reviewed to evaluate the presence of CCAs. Cardiovascular mortality was assessed as the main clinical outcome. Results Forty patients were found to have CCAs. Patients with CCAs have lower CFVR than those without CCAs (2.22 ± 0.72 versus 2.69 ± 0.92;P = 0.003), reflecting in different rates of CMD in the 2 groups (72.5% versus 37%; P < 0.001). CMD is associated with higher CAV grades (P < 0.001), which are also associated with CCAs (P < 0.001). Patients with poorly developed CCAs have lower CFVR (P < 0.001). At multivariable analysis, CMD (P = 0.008) and higher CAV grades (P = 0.005) are independent predictors of CCAs. During the median follow-up time of 10.2 (6.6-13.3) y, patients with CCAs have been found to have higher mortality than those without CCAs (57.5% versus 32.1%; P = 0.007). CCAs are associated with a lower probability of survival also in patients with CMD (P < 0.001) and are independent predictors of mortality (P < 0.001). Conclusions Our results demonstrate an interplay between CAV, CMD, and CCAs. We confirm that CAV is associated with CMD, and we show, for the first time, that CMD is associated with CCAs. CCAs are pathophysiologically associated with more severe graft vasculopathy and independently predict mortality after HT.
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Affiliation(s)
- Giovanni Civieri
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giulia Masiero
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Elena Osto
- Department of Cardiology, Heart Center, University Hospital Zurich and University of Zürich, Zurich, Switzerland
- Institute for Clinical Chemistry, University Hospital Zurich and University of Zürich, Zurich, Switzerland
| | - Antonio Gambino
- Division of Cardiac Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Annalisa Angelini
- Cardiac Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Angela Fraiese
- Department of Cardiology, Heart Center, University Hospital Zurich and University of Zürich, Zurich, Switzerland
| | - Marny Fedrigo
- Cardiac Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giuseppe Toscano
- Department of Cardiology, Heart Center, University Hospital Zurich and University of Zürich, Zurich, Switzerland
| | - Tomaso Bottio
- Department of Cardiology, Heart Center, University Hospital Zurich and University of Zürich, Zurich, Switzerland
| | - Martina Perazzolo Marra
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Sabino Iliceto
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Gino Gerosa
- Department of Cardiology, Heart Center, University Hospital Zurich and University of Zürich, Zurich, Switzerland
| | - Francesco Tona
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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Azzalini L, Moroni F, Dawson KL, Kearney KE. Chronic total occlusion percutaneous coronary intervention in heart transplant patients. Catheter Cardiovasc Interv 2023; 101:102-107. [PMID: 36378679 DOI: 10.1002/ccd.30476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/31/2022] [Accepted: 11/02/2022] [Indexed: 11/17/2022]
Abstract
Cardiac allograft vasculopathy (CAV) is frequently observed after heart transplant (HT), and represents one of the main causes of chronic rejection, graft loss, and death. While the role of percutaneous coronary intervention (PCI) is well established in the management of CAV in cases of nonocclusive stenoses, the outcomes and technical aspects of this procedure in chronic total occlusions (CTOs) are unknown. We describe our experience with three cases in which CTO PCI was indicated to treat CAV in HT recipients, and we discuss the peculiarities and therapeutic approach to this challenging patient population. In particular, all patients were asymptomatic for angina, and CTO PCI was indicated to promote recovery of left ventricular function, extend graft survival, and/or protect from future ischemic events. CTO PCI was performed using hybrid techniques and was successful in all three cases. Intravascular imaging was used in all cases to maximize the durability of the procedure.
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Affiliation(s)
- Lorenzo Azzalini
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Francesco Moroni
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Kathryn L Dawson
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA.,Division of Cardiology, Department of Medicine, Montefiore Medical Center, The Bronx, New York, USA
| | - Kathleen E Kearney
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
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11
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Cardiac Allograft Vasculopathy in Pediatric Heart Transplant Recipients Does Early-Onset Portend a Worse Prognosis? J Heart Lung Transplant 2022; 41:578-588. [DOI: 10.1016/j.healun.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 12/05/2021] [Accepted: 01/08/2022] [Indexed: 11/19/2022] Open
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12
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Lee JW. Multiparametric Cardiac Magnetic Resonance Imaging for Diagnosing Cardiac Allograft Vasculopathy. J Cardiovasc Imaging 2022; 30:276-278. [PMID: 36280268 PMCID: PMC9592251 DOI: 10.4250/jcvi.2022.0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/03/2022] [Accepted: 07/06/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Ji Won Lee
- Department of Radiology, Pusan National University Hospital, Pusan National University School of Medicine and Medical Research Institute, Busan, Korea
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13
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Analysis of Fibrotic Plaques in Angiographic Manifest Cardiac Allograft Vasculopathy in Long-term Heart Transplanted Patients Using Optical Coherence Tomography. Transplant Direct 2021; 8:e1266. [PMID: 34966839 PMCID: PMC8710340 DOI: 10.1097/txd.0000000000001266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/24/2021] [Accepted: 10/26/2021] [Indexed: 12/02/2022] Open
Abstract
Supplemental Digital Content is available in the text. Background. The development and progression of cardiac allograft vasculopathy documented by coronary angiography (CAVangio) after heart transplantation (HTx) has prognostic relevance. Yet there are limited data regarding the role of concomitant intracoronary imaging in the presence CAVangio. In particular, atherosclerotic plaques might represent a potential target for prevention, but their impact on stenosis is understudied. Methods. We used high-resolution intracoronary optical coherence tomography (OCT) to quantify and compare findings of intimal hyperplasia (IH) and plaque morphologies in HTx patients (fibrotic plaque, lipid plaque, and calcified plaque). OCT findings were related to the presence of CAVangio as well as to the severity of stenosis. Results. We included 65 consecutive patients into analysis (66% with CAVangio, posttransplant interval 9.9 ± 7.6 y). Fibrotic, lipid, and calcified plaques were present in 41 (63.1%), 39 (60%), and 18 (27.7%) patients, respectively. In addition to IH, the presence of fibrotic, lipid, and calcified plaques was found to be associated with CAVangio. The prevalence of lipid plaque and quantitative measurements of fibrotic plaque increased with stenosis severity (lipid plaque, P < 0.001, maximal and mean fibrotic arc, P = 0.05 and P = 0.001, respectively). Receiver operating characteristic analysis showed that area under the curve of the fibrotic plaque parameter mean fibrotic arc (0.87, 95% confidence interval [0.76-0.99]; P = 0.002) was superior to area under the curve of intima parameters regarding CAVangio. The effect of mean fibrotic arc (r = 0.52, P < 0.001) was relevant regarding stenosis severity. Conclusions. After a longer posttransplant interval, CAV findings in OCT included a combination of IH and atherosclerotic plaques. In addition to IH, the presence of fibrotic, lipid, and calcified plaques is associated with CAVangio. Further studies are warranted to evaluate if the in vivo screening for plaque progress, particularly of fibrotic plaque, could improve individual secondary prevention and outcome in HTx patients.
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14
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Pober JS, Chih S, Kobashigawa J, Madsen JC, Tellides G. Cardiac allograft vasculopathy: current review and future research directions. Cardiovasc Res 2021; 117:2624-2638. [PMID: 34343276 PMCID: PMC8783389 DOI: 10.1093/cvr/cvab259] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/02/2021] [Accepted: 07/29/2021] [Indexed: 12/25/2022] Open
Abstract
Cardiac allograft vasculopathy (CAV) is a pathologic immune-mediated remodelling of the vasculature in transplanted hearts and, by impairing perfusion, is the major cause of late graft loss. Although best understood following cardiac transplantation, similar forms of allograft vasculopathy occur in other vascularized organ grafts and some features of CAV may be shared with other immune-mediated vasculopathies. Here, we describe the incidence and diagnosis, the nature of the vascular remodelling, immune and non-immune contributions to pathogenesis, current therapies, and future areas of research in CAV.
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MESH Headings
- Adaptive Immunity
- Animals
- Coronary Artery Disease/epidemiology
- Coronary Artery Disease/immunology
- Coronary Artery Disease/metabolism
- Coronary Artery Disease/pathology
- Coronary Vessels/immunology
- Coronary Vessels/metabolism
- Coronary Vessels/pathology
- Endothelial Cells/immunology
- Endothelial Cells/metabolism
- Endothelial Cells/pathology
- Graft Rejection/epidemiology
- Graft Rejection/immunology
- Graft Rejection/metabolism
- Graft Rejection/pathology
- Graft Survival
- Heart Transplantation/adverse effects
- Humans
- Immunity, Innate
- Muscle, Smooth, Vascular/immunology
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/pathology
- Myocytes, Smooth Muscle/immunology
- Myocytes, Smooth Muscle/metabolism
- Myocytes, Smooth Muscle/pathology
- Risk Factors
- Signal Transduction
- Treatment Outcome
- Vascular Remodeling
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Affiliation(s)
- Jordan S Pober
- Department of Immunobiology, Pathology and Dermatology, Yale School of Medicine, 10 Amistad Street, New Haven CT 06520-8089, USA
| | - Sharon Chih
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Jon Kobashigawa
- Department of Medicine, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Joren C Madsen
- Division of Cardiac Surgery and Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - George Tellides
- Department of Surgery (Cardiac Surgery), Yale School of Medicine, New Haven, CT, USA
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15
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Cardiac allograft vasculopathy: Caveats and perspectives. Trends Cardiovasc Med 2021; 32:339-340. [PMID: 34371158 DOI: 10.1016/j.tcm.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 07/31/2021] [Accepted: 07/31/2021] [Indexed: 12/07/2022]
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16
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Nous FMA, Roest S, van Dijkman ED, Attrach M, Caliskan K, Brugts JJ, Nieman K, Hirsch A, Constantinescu AA, Manintveld OC, Budde RPJ. Clinical implementation of coronary computed tomography angiography for routine detection of cardiac allograft vasculopathy in heart transplant patients. Transpl Int 2021; 34:1886-1894. [PMID: 34268796 PMCID: PMC8519137 DOI: 10.1111/tri.13973] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/04/2021] [Accepted: 07/08/2021] [Indexed: 12/01/2022]
Abstract
Cardiac allograft vasculopathy (CAV) is an accelerated form of coronary artery disease that affects long‐term outcomes in heart transplant (HTx) patients. We prospectively evaluated the feasibility of coronary computed tomography angiography (CCTA) for the detection of CAV during clinical implementation at our center. All consecutive HTx patients >4 years post‐transplant were actively converted from myocardial perfusion imaging to CCTA for the annual assessment of CAV. Between February 2018 and May 2019, 129/172 (75%) HTx patients underwent a CCTA. Renal impairment (n = 21/43) was the most frequent reason for patients could not undergo CCTA. CCTA image quality was good–excellent in 118/129 (92%) patients, and the radiation dose was 2.1 (1.6–2.8) mSv. CCTA showed obstructive CAV in 19/129 (15%) patients. Thirteen (10%) patients underwent additional tests, of which 8 patients underwent coronary revascularization within 90 days of CCTA. After 1 year, 3 additional coronary angiograms were performed, resulting in one revascularization in a patient with known severe CAV who developed ventricular tachycardia. One myocardial infarction after coronary stenting and 2 non‐cardiac deaths were observed. CCTA can be successfully implemented for routine detection of CAV with good image quality and low radiation dose. CCTA allows CAV evaluation with the limited need for additional invasive testing.
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Affiliation(s)
- Fay M A Nous
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.,Department of Cardiology, Thorax Center, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Stefan Roest
- Department of Cardiology, Thorax Center, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.,Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Eva D van Dijkman
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.,Department of Cardiology, Thorax Center, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Mohamed Attrach
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Thorax Center, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.,Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jasper J Brugts
- Department of Cardiology, Thorax Center, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.,Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Koen Nieman
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.,Department of Cardiology, Thorax Center, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.,Stanford University School of Medicine, Cardiovascular Institute, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Alexander Hirsch
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.,Department of Cardiology, Thorax Center, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Alina A Constantinescu
- Department of Cardiology, Thorax Center, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.,Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Olivier C Manintveld
- Department of Cardiology, Thorax Center, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.,Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ricardo P J Budde
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.,Department of Cardiology, Thorax Center, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
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17
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Fluschnik N, Geelhoed B, Becher PM, Schrage B, Brunner FJ, Knappe D, Bernhardt AM, Blankenberg S, Kobashigawa J, Reichenspurner H, Schnabel RB, Magnussen C. Non-immune risk predictors of cardiac allograft vasculopathy: Results from the U.S. organ procurement and transplantation network. Int J Cardiol 2021; 331:57-62. [PMID: 33571561 DOI: 10.1016/j.ijcard.2021.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/31/2020] [Accepted: 02/04/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) remains a major long-term complication in heart transplant (HT) recipients related to increased mortality. We aimed to identify non-immune recipient- and donor-related risk factors for the development of CAV in HT patients. METHODS 40,647 recipients, prospectively enrolled from April 1995 to January 2019 in the Organ Procurement and Transplantation Network (OPTN), were analyzed after exclusion of pediatric patients, those with missing information on CAV, and re-transplantation. Multivariable-adjusted Cox regression analyses were performed to identify recipient- and donor-related risk factors for CAV. 5-year population attributable risk for classical cardiovascular risk factors was calculated to estimate the recipients' CAV risk. Analyses were based on OPTN data (June 30, 2019). RESULTS Of 40,647 post-transplant patients, 14,698 (36.2%) developed CAV with a higher incidence in males (37.3%) than in females (32.6%) (p < 0.001). The mean follow-up time was 68.2 months. In recipients, male sex, African American and Asian ethnicity, ischemic cardiomyopathy, body mass index and smoking were associated with CAV occurrence. In donors, older age, male sex, smoking, diabetes and arterial hypertension were related to CAV. Results remained fairly stable after analysis of different time periods. 5-year attributable CAV risk for classical cardiovascular risk factors was 9.1%. CONCLUSIONS In this large registry with known limitations concerning data completeness, CAV incidence was higher in males than in females. Next to male sex and donor age, the classical cardiovascular risk factors were related to incident CAV. Classical cardiovascular risk factors played only a minor role for the 5-year attributable CAV risk.
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Affiliation(s)
- Nina Fluschnik
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Germany
| | - Bastiaan Geelhoed
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Germany
| | - Peter Moritz Becher
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Germany
| | - Fabian J Brunner
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Dorit Knappe
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Germany
| | - Jon Kobashigawa
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Germany
| | - Christina Magnussen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Germany.
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18
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Vessel Fractional Flow Reserve and Graft Vasculopathy in Heart Transplant Recipients. J Interv Cardiol 2020; 2020:9835151. [PMID: 32733172 PMCID: PMC7376430 DOI: 10.1155/2020/9835151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 05/12/2020] [Indexed: 11/18/2022] Open
Abstract
Background Cardiac allograft vasculopathy (CAV) remains the Achilles' heel of long-term survival after heart transplantation (HTx). The severity and extent of CAV is graded with conventional coronary angiography (COR) which has several limitations. Recently, vessel fractional flow reserve (vFFR) derived from COR has emerged as a diagnostic computational tool to quantify the functional severity of coronary artery disease. Purpose The present study assessed the usefulness of vFFR to detect CAV in HTx recipients. Methods In HTx patients referred for annual check-up, undergoing surveillance COR, the extent of CAV was graded according to the criteria proposed by the international society of heart and lung transplantation (ISHLT). In addition, three-dimensional coronary geometries were constructed from COR to calculate pressure losses using vFFR. Results In 65 HTx patients with a mean age of 53.7 ± 10.1 years, 8.5 years (IQR 1.90, 15.2) years after HTx, a total number of 173 vessels (59 LAD, 61 LCX, and 53 RCA) were analyzed. The mean vFFR was 0.84 ± 0.15 and median was 0.88 (IQR 0.79, 0.94). A vFFR ≤ 0.80 was present in 24 patients (48 vessels). HTx patients with a history of ischemic cardiomyopathy (ICMP) had numerically lower vFFR as compared to those with non-ICMP (0.70 ± 0.22 vs. 0.79 ± 0.13, p = 0.06). The use of vFFR reclassified 31.9% of patients compared to the anatomical ISHLT criteria. Despite a CAV score of 0, a pathological vFFR ≤ 0.80 was detected in 8 patients (34.8%). Conclusion The impairment in epicardial conductance assessed by vFFR in a subgroup of patients without CAV according to standard ISHLT criteria suggests the presence of a diffuse vasculopathy undetectable by conventional angiography. Therefore, we speculate that vFFR may be useful in risk stratification after HTx.
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19
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Picão S, Oliveira-Santos M, Batista M, Prieto D, Antunes MJ, Pego M, Matos V, Gonçalves L, Jorge E. Cardiac allograft vasculopathy: Incidence and predictors in a single-center cohort. Rev Port Cardiol 2020; 39:205-212. [PMID: 32471665 DOI: 10.1016/j.repc.2019.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 10/08/2019] [Accepted: 10/27/2019] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION AND AIMS Cardiac allograft vasculopathy (CAV) is one of the most significant complications after orthotopic heart transplantation. We aimed to investigate the incidence and predictors of CAV in a large cohort of orthotopic heart transplantation patients. METHODS We conducted a retrospective analysis on a prospective cohort of 233 patients who underwent transplantation between November 2003 and May 2014. Baseline clinical data and invasive coronary angiograms (n=712) performed as part of the follow-up program were analyzed by two independent investigators. RESULTS We included 157 male and 45 female patients with a median age of 66 years. A third of patients had previous ischemic heart disease, 30% peripheral arterial disease, 37% hypertension and 47% dyslipidemia, and 17% were smokers. Acute moderate or severe rejection occurred in 42 patients during the first year. Over a median follow-up of 2920 days, 18% were diagnosed with CAV, with an incidence of 2.91 cases per 100 person-years. Predictors of CAV were previous ischemic heart disease (HR 2.32, 95% CI 1.21-4.45, p=0.01), carotid artery disease (HR 2.44, 95% CI 1.27-4.71, p<0.01), and donor age (HR 1.04, 95% CI 1.00-1.07, p=0.01). CONCLUSION In a single-center cohort of orthotopic heart transplantation patients, predictors of CAV were previous ischemic heart disease, carotid artery disease and donor age.
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Affiliation(s)
- Sofia Picão
- Centro Hospitalar da Universidade de Coimbra, Coimbra, Portugal.
| | | | - Manuel Batista
- Centro Hospitalar da Universidade de Coimbra, Coimbra, Portugal
| | - David Prieto
- Centro Hospitalar da Universidade de Coimbra, Coimbra, Portugal
| | | | - Mariano Pego
- Centro Hospitalar da Universidade de Coimbra, Coimbra, Portugal
| | - Vítor Matos
- Centro Hospitalar da Universidade de Coimbra, Coimbra, Portugal
| | - Lino Gonçalves
- Centro Hospitalar da Universidade de Coimbra, Coimbra, Portugal
| | - Elisabete Jorge
- Centro Hospitalar da Universidade de Coimbra, Coimbra, Portugal
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20
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Spitaleri G, Farrero Torres M, Sabatino M, Potena L. The pharmaceutical management of cardiac allograft vasculopathy after heart transplantation. Expert Opin Pharmacother 2020; 21:1367-1376. [PMID: 32401066 DOI: 10.1080/14656566.2020.1753698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Cardiac allograft vasculopathy (CAV) is a major limitation to long-term survival after heart transplantation. Its peculiar pathophysiology involves multifactorial pathways including immune-mediated and metabolic risk factors, which are associated with the development of specific pathological lesions. The often diffuse and chronic nature of the disease reduces the effectiveness of revascularization procedures, and pharmacological prevention of the disease is the sole therapeutic approach with some proven efficacy. AREAS COVERED In this article, after briefly outlining the risk factors for CAV, the authors revise the potential pharmacological approaches that may reduce the burden of CAV. While several therapies have shown convincing efficacy in terms of CAV prevention diagnosed by coronary imaging, very few have been reported to improve prognosis with any meaningful level of evidence. EXPERT OPINION The authors believe that a customizable approach is necessary for clinical practice given the currently available evidence. Furthermore, it is important, in the future, to address the glaring therapeutic gap of an effective treatment against donor-specific antibodies, whose effect on endothelial injury is currently one of the major mechanisms of CAV development and for which no pharmacological treatment is currently available.
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Affiliation(s)
- Giosafat Spitaleri
- Heart Failure and Heart Transplant Unit, Cardiovascular Institute, Hospital Clínic , Barcelona, Spain
| | - Marta Farrero Torres
- Heart Failure and Heart Transplant Unit, Cardiovascular Institute, Hospital Clínic , Barcelona, Spain
| | - Mario Sabatino
- Heart Failure and Heart Transplant Program, Bologna Academic Hospital , Bologna, Italy
| | - Luciano Potena
- Heart Failure and Heart Transplant Program, Bologna Academic Hospital , Bologna, Italy
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21
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Picão S, Oliveira-Santos M, Batista M, Prieto D, Antunes MJ, Pego M, Matos V, Gonçalves L, Jorge E. Cardiac allograft vasculopathy: Incidence and predictors in a single-center cohort. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.repce.2019.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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22
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McGuinty C, Moayedi Y, Chih S. Outcomes according to the International Society for Heart and Lung Tansplantation angiographic grading scale. J Heart Lung Transplant 2020; 39:847-848. [PMID: 32088109 DOI: 10.1016/j.healun.2020.01.1346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 01/24/2020] [Indexed: 10/25/2022] Open
Affiliation(s)
- Caroline McGuinty
- Ted Rogers Centre of Excellence, Peter Munk Cardiac Centre in Heart Function, University Health Network, Toronto, Ontario, Canada
| | - Yasbanoo Moayedi
- Ted Rogers Centre of Excellence, Peter Munk Cardiac Centre in Heart Function, University Health Network, Toronto, Ontario, Canada
| | - Sharon Chih
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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23
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Lee F, Nair V, Chih S. Cardiac allograft vasculopathy: Insights on pathogenesis and therapy. Clin Transplant 2020; 34:e13794. [PMID: 31991002 DOI: 10.1111/ctr.13794] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 01/14/2020] [Accepted: 01/23/2020] [Indexed: 12/21/2022]
Abstract
Cardiac allograft vasculopathy (CAV) is a unique accelerated form of coronary vascular disease affecting heart transplant recipients. This complication is a significant contributor to medium- to long-term post-transplant morbidity and mortality. There is a high prevalence of CAV with approximately one in three patients developing CAV by 5 years post-transplant. Morphologically, CAV is characterized by concentric coronary intimal hyperplasia in both the epicardial arteries and intramural microvasculature. Although several immune and non-immune factors have been identified, their precise pathogenic mechanisms, interactions, and relative importance in the development of CAV are not well defined. The advent of improved imaging surveillance modalities has resulted in earlier detection during the disease process. However, overall management of CAV remains challenging due to paucity of treatment. This review aims to discuss key concepts on the pathogenesis of CAV and current management strategies, focusing on the use of mammalian target of rapamycin inhibitors.
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Affiliation(s)
- Felicity Lee
- Heart Failure and Transplantation, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Vidhya Nair
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sharon Chih
- Heart Failure and Transplantation, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada
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24
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Bellumkonda L, Patel J. Recent advances in the role of mammalian target of rapamycin inhibitors on cardiac allograft vasculopathy. Clin Transplant 2019; 34:e13769. [DOI: 10.1111/ctr.13769] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/02/2019] [Accepted: 12/05/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Lavanya Bellumkonda
- Division of Cardiology Department of Medicine Yale School of Medicine New Haven CT USA
| | - Jignesh Patel
- Cedars‐Sinai Medical Center Smidt Heart Institute Los Angeles CA USA
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Van Keer JM, Van Aelst LN, Rega F, Droogne W, Voros G, Meyns B, Vanhaecke J, Emonds MP, Janssens S, Naesens M, Van Cleemput J. Long-term outcome of cardiac allograft vasculopathy: Importance of the International Society for Heart and Lung Transplantation angiographic grading scale. J Heart Lung Transplant 2019; 38:1189-1196. [DOI: 10.1016/j.healun.2019.08.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/25/2019] [Accepted: 08/07/2019] [Indexed: 12/12/2022] Open
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Nikolova AP, Kobashigawa JA. Cardiac Allograft Vasculopathy: The Enduring Enemy of Cardiac Transplantation. Transplantation 2019; 103:1338-1348. [PMID: 31241553 DOI: 10.1097/tp.0000000000002704] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Cardiac allograft vasculopathy remains a major limiting factor in the long-term survival of the heart transplant recipient. Our understanding of its pathogenesis is continuously evolving as advances in imaging modalities have allowed a direct window into the natural history of the disease. Innovation in diagnostic modalities has spurred the proliferation of prognostic tools and biomarkers. And in parallel, pharmacological advances have emerged that have helped ameliorate the disease's progressive course.
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Affiliation(s)
- Andriana P Nikolova
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jon A Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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28
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Berg K, Clemmensen TS, Tram EM, Koefoed-Nielsen P, Ilkjaer LB, Poulsen SH, Eiskjaer H. Survival, graft function, and incidence of allograft vasculopathy in heart transplant patients receiving adverse risk profile donor hearts. Clin Transplant 2018; 32:e13343. [DOI: 10.1111/ctr.13343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/05/2018] [Accepted: 06/25/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Katrine Berg
- Department of Cardiology; Aarhus University Hospital; Skejby, Aarhus Denmark
| | - Tor S. Clemmensen
- Department of Cardiology; Aarhus University Hospital; Skejby, Aarhus Denmark
| | - Else Marie Tram
- Department of Cardiology; Aarhus University Hospital; Skejby, Aarhus Denmark
| | | | - Lars B. Ilkjaer
- Department of Cardiothoracic and Vascular Surgery; Aarhus University Hospital; Skejby, Aarhus Denmark
| | - Steen H. Poulsen
- Department of Cardiology; Aarhus University Hospital; Skejby, Aarhus Denmark
| | - Hans Eiskjaer
- Department of Cardiology; Aarhus University Hospital; Skejby, Aarhus Denmark
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