1
|
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.
Collapse
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
Collapse
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
| |
Collapse
|
2
|
Reduced Function of Endothelial Nitric Oxide and Hyperpolarization in Artery Grafts with Poor Runoff. J Surg Res 2021; 270:2-11. [PMID: 34626903 DOI: 10.1016/j.jss.2021.08.031] [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: 03/24/2021] [Revised: 08/05/2021] [Accepted: 08/27/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND The endothelium regulates vascular tonus by releasing nitric oxide (endothelium-derived nitric oxide, EDNO) and hyperpolarizing factor (endothelium-derived hyperpolarizing factor, EDHF). In vein grafts with poor runoff, lack of function of these factors causes severe intimal hyperplasia. This study evaluated how the functions of EDNO and EDHF are altered in artery grafts under poor runoff conditions. MATERIALS AND METHODS The right common carotid arteries of rabbits were excised and implanted in their original positions as autogenous grafts under normal runoff conditions ("nonoccluded grafts") or poor runoff conditions ("poor runoff grafts"). Histochemical changes, acetylcholine (ACh)-induced effects on endothelium-dependent relaxation and smooth muscle cell (SMC) hyperpolarization were examined. RESULTS Both artery graft types displayed negligible intimal hyperplasia. In the absence and presence of an EDNO synthase inhibitor, ACh-induced relaxation was lower in grafts with poor runoff than in nonoccluded grafts. Furthermore, ACh-induced but not nonreceptor agonist A23187-induced SMC hyperpolarization was lower in the poor runoff graft group than in the nonoccluded graft group. CONCLUSIONS Unlike in those in vein grafts, the functions of EDNO and EDHF in autogenous carotid artery grafts under poor runoff conditions were reduced but partly maintained. In such artery grafts, intimal hyperplasia caused by surgical operation was not present. These results may explain some of the mechanisms underlying the improved patency of artery grafts compared with vein grafts.
Collapse
|
3
|
Fearon WF, Felix R, Hirohata A, Sakurai R, Jose PO, Yamasaki M, Nakamura M, Fitzgerald PJ, Valantine HA, Yock PG, Yeung AC. The effect of negative remodeling on fractional flow reserve after cardiac transplantation. Int J Cardiol 2017; 241:283-287. [PMID: 28413112 DOI: 10.1016/j.ijcard.2017.04.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 04/01/2017] [Accepted: 04/07/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Negative remodeling is a common occurrence early after cardiac transplantation. Its impact on the development of myocardial ischemia is not well documented. The aim of this study is to investigate the impact of negative remodeling on fractional flow reserve after cardiac transplantation. METHODS Thirty-four cardiac transplant recipients underwent intravascular ultrasound (IVUS) and fractional flow reserve (FFR) assessment soon after transplantation and one year later. Patients were divided into those with and without negative remodeling based on IVUS, and the impact on FFR was assessed. In the 19 patients with negative remodeling, there was no significant change in plaque volume (119.3±82.0 to 131.3±91.2mm3, p=0.21), but vessel volume (775.6±212.0 to 621.9±144.1mm3, p<0.0001) and lumen volume (656.3±169.1 to 490.7±132.0mm3, p<0.0001) decreased significantly and FFR likewise decreased significantly (0.88±0.06 to 0.84±0.07, p=0.04). In the 15 patients without negative remodeling, vessel volume did not change (711.7±217.6 to 745.7±198.5, p=0.28), but there was a significant increase in plaque volume (126.8±88.3 to 194.4±92.7, p<0.001) and a resultant significant decrease in FFR (0.89±0.05 to 0.85±0.05, p=0.01). CONCLUSION Negative remodeling itself, without any change in plaque volume can cause a significant decrease in fractional flow reserve after cardiac transplantation and appears to be another possible mechanism for myocardial ischemia.
Collapse
Affiliation(s)
- William F Fearon
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States.
| | - Robert Felix
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| | - Atsushi Hirohata
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| | - Ryota Sakurai
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| | - Powell O Jose
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| | - Masao Yamasaki
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| | - Mamoo Nakamura
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| | - Peter J Fitzgerald
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| | - Hannah A Valantine
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| | - Paul G Yock
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| | - Alan C Yeung
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| |
Collapse
|
4
|
Goto K, Iakovou I, Gkouziouta A, Maehara A, Mintz GS, Karavolias G, Leontiadis V, Voudris V, Pavlides G, Adamopoulos S. Intravascular Ultrasonic Imaging of Coronary Arterial Remodeling in Heart Transplant Recipients. Am J Cardiol 2015; 116:785-90. [PMID: 26100587 DOI: 10.1016/j.amjcard.2015.05.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 05/20/2015] [Accepted: 05/20/2015] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to evaluate long-term changes of transplant coronary arteries, including vessel, plaque, and lumen areas. There are limited long-term data on vessel remodeling after heart transplantation. We analyzed serial intravascular ultrasound images of the left anterior descending coronary artery (LAD) in 54 heart transplantation recipients. Nine patients (16.7%) had a history of rejection. Proximal left anterior descending artery segments were matched among time points, a ≥20-mm long segment was analyzed every 1 mm, and results were normalized for analysis length and reported as mm(3)/mm. During follow-up, vessel area decreased (-0.48 ± 1.3 mm(3)/mm/year), and plaque area did not change (-0.01 ± 0.47 mm(3)/mm/year). As a result, lumen area decreased (-0.52 ± 1.34 mm(3)/mm/year). The change in mean lumen area was well correlated to the change in mean vessel area (r = 0.94, p <0.01) but not to the change in mean plaque area (r = -0.27, p = 0.05). In conclusion, lumen loss occurred during long-term follow-up of patients who underwent heart transplantation, primarily secondary to negative remodeling (decrease in vessel dimensions).
Collapse
Affiliation(s)
- Kosaku Goto
- Cardiovascular Research Foundation, New York, New York; Columbia University Medical Center, New York, New York
| | | | | | - Akiko Maehara
- Cardiovascular Research Foundation, New York, New York; Columbia University Medical Center, New York, New York.
| | - Gary S Mintz
- Cardiovascular Research Foundation, New York, New York
| | | | | | | | | | | |
Collapse
|
5
|
Impact of Donor-Transmitted Atherosclerosis on Early Cardiac Allograft Vasculopathy: New Findings by Three-Dimensional Intravascular Ultrasound Analysis. Transplantation 2011; 91:1406-11. [DOI: 10.1097/tp.0b013e31821ab91b] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
6
|
|
7
|
Wang Y, Ahmad U, Yi T, Zhao L, Lorber MI, Pober JS, Tellides G. Alloimmune-mediated vascular remodeling of human coronary artery grafts in immunodeficient mouse recipients is independent of preexisting atherosclerosis. Transplantation 2007; 83:1501-5. [PMID: 17565324 DOI: 10.1097/01.tp.0000264560.51845.67] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Vascular remodeling rather than intimal thickening is the most important determinant of luminal loss in cardiac graft arteriosclerosis. The impact of donor-transmitted atherosclerotic lesions on alloimmune-mediated arterial injury in an experimental setting is not known. We investigated this issue in a chimeric model of human coronary artery grafts to immunodeficient mouse recipients reconstituted with allogeneic human peripheral blood mononuclear cells. Rejecting grafts demonstrated robust intimal expansion, outward vascular remodeling, and variable lumen loss. There was no significant relationship between preexistent atherosclerosis, gender, and age of the artery donors vs. the degree of alloimmune-induced changes in vessel morphology. Our experimental findings, in a system without the potentially confounding variable of immunosuppressive drugs, are in agreement with the majority of clinical studies that alloimmune-mediated intimal injury and vascular remodeling is independent of preexisting coronary atherosclerosis. Our results support the concept of extending the criteria for organ donors to include modest coronary atherosclerosis.
Collapse
Affiliation(s)
- Yinong Wang
- Interdepartmental Program in Vascular Biology and Transplantation, Yale University School of Medicine, New Haven, CT, USA
| | | | | | | | | | | | | |
Collapse
|
8
|
Fearon WF, Potena L, Hirohata A, Sakurai R, Yamasaki M, Luikart H, Lee J, Vana ML, Cooke JP, Mocarski ES, Yeung AC, Valantine HA. Changes in coronary arterial dimensions early after cardiac transplantation. Transplantation 2007; 83:700-5. [PMID: 17414701 DOI: 10.1097/01.tp.0000256335.84363.9b] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Significant changes in coronary artery structure, including intimal thickening and vessel remodeling, occur early after cardiac transplantation. The degree to which these changes compromise coronary lumen dimensions, and the clinical factors that affect these changes, remain controversial. METHODS Thirty-eight adult cardiac transplant recipients underwent coronary angiography and volumetric intravascular ultrasound (IVUS) evaluation of the left anterior descending artery within 8 weeks of transplantation and at 1 year. Clinical parameters including donor and recipient characteristics, rejection episodes, and serology were prospectively recorded. Two-dimensional IVUS measurements and vessel, lumen and plaque volume were calculated at both time points and compared. Multivariate regression analysis was performed to reveal clinical predictors of change in coronary dimensions. RESULTS During the first year after transplantation, significant decreases in vessel size (negative remodeling) and lumen size were observed with significant increases in plaque burden based on IVUS analyses. Loss of lumen volume correlated significantly with the degree of negative remodeling (R=0.82, P<0.0001), but not with changes in plaque burden (R=0.08, P=0.64). Patients with the greatest increase in plaque volume had significantly less negative remodeling (R=0.53, P=0.0006). Transplant recipient cytomegalovirus (CMV) antibody seropositivity and lack of aggressive prophylaxis against CMV infection/reactivation were significant independent predictors of greater negative remodeling (P<0.01 and P=0.03, respectively) and greater lumen loss (P=0.02 and P=0.03, respectively). CONCLUSION Negative remodeling is primarily responsible for coronary artery lumen loss during the first year after cardiac transplantation. CMV seropositivity and lack of aggressive CMV prophylaxis correlate with increased negative remodeling, resulting in greater lumen loss.
Collapse
Affiliation(s)
- William F Fearon
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA 94305-5637, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Park KM, Kim JJ, Hong MK, Lee CW, Kim YH, Park SW, Park SJ. Characteristics of Transplant Coronary Artery Disease after Heart Transplantation in Koreans: A Serial Intravascular UltraSound Analysis. Korean Circ J 2007. [DOI: 10.4070/kcj.2007.37.1.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Kyoung-Min Park
- Department of Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jae-Joong Kim
- Department of Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Myeong-Ki Hong
- Department of Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Cheol Whan Lee
- Department of Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Young-Hak Kim
- Department of Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seong-Wook Park
- Department of Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seung-Jung Park
- Department of Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| |
Collapse
|
10
|
Li H, Tanaka K, Chhabra A, Oeser B, Kobashigawa JA, Tobis JM. Vascular Remodeling 1 Year After Cardiac Transplantation. J Heart Lung Transplant 2007; 26:56-62. [PMID: 17234518 DOI: 10.1016/j.healun.2006.10.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2005] [Revised: 10/11/2006] [Accepted: 10/19/2006] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND The belief that vascular remodeling and intimal hyperplasia are causes of luminal narrowing in cardiac allograft vasculopathy (CAV) is controversial. This study evaluated the relationship of vascular remodeling and intimal hyperplasia to luminal narrowing 1 year after orthotopic heart transplantation. METHODS Intravascular ultrasound imaging was performed on 190 cardiac transplant recipients at baseline and again 1 year after transplantation as part of a randomized trial of mycophenolate mofetil (MMF) and azathioprine (Aza). Studies 1 year apart were matched at 625 sites. All sites were classified into positive, non-significant and negative remodeling patterns, depending on a change of +/-10% in external elastic membrane area. Of the 190 patients, 99 were randomized to receive MMF, and 91 to receive Aza. RESULTS A total of 625 sites were observed. Of these, 52% had no remodeling, 25% exhibited vessel dilation, and 23% had vessel shrinkage in the presence of variable intimal growth (Delta intimal area: 0.73 +/- 1.70 mm2, p < 0.0001; 1.23 +/- 2.02 mm2, p < 0.0001; and 0.20 +/- 1.40 mm2, p = 0.09, respectively). Sixty percent of the lumen loss was due to a decrease in external elastic membrane area and 40% to an increase in intimal area (p = 0.005). Compared with Aza-treated patients, the MMF-treated patients had a lower incidence of vessel shrinkage (17% vs 28%, p = 0.001), and a trend for smaller maximum intimal thickness (0.21 +/- 0.25 mm vs 0.29 +/- 0.31 mm, p = 0.052). CONCLUSIONS Positive remodeling is associated with intimal growth, but negative remodeling does not correlate with any specific change in intimal hyperplasia. Constrictive remodeling is more responsible than intimal hyperplasia for the luminal narrowing that occurs. MMF is more efficacious than azathioprine in preventing the development of CAV at 1 year, by reducing the degree and incidence of vessel shrinkage and the progression of intimal hyperplasia.
Collapse
Affiliation(s)
- Haiyan Li
- Department of Medicine, Division of Cardiology, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, California, USA
| | | | | | | | | | | |
Collapse
|
11
|
Li H, Tanaka K, Anzai H, Oeser B, Lai D, Kobashigawa JA, Tobis JM. Influence of Pre-Existing Donor Atherosclerosis on the Development of Cardiac Allograft Vasculopathy and Outcomes in Heart Transplant Recipients. J Am Coll Cardiol 2006; 47:2470-6. [PMID: 16781375 DOI: 10.1016/j.jacc.2006.01.072] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2005] [Revised: 01/10/2006] [Accepted: 01/16/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES This study sought to evaluate the influence of donor lesions on the development of cardiac allograft vasculopathy and outcomes in heart transplant recipients. BACKGROUND After orthotopic heart transplantation (OHT), coronary artery narrowing occurs as a combination of pre-existing donor lesions and new lesions that develop as a result of cardiac allograft vasculopathy. METHODS Intravascular ultrasound (IVUS) studies were performed in 301 recipients at 1.3 +/- 0.6 months and again at 12.2 +/- 0.8 months after OHT. Additional IVUS studies were performed in 90 patients at two and three years of follow-up. Sites at baseline with maximum intimal thickness > or =0.5 mm were defined as pre-existing donor lesions. The angiographic diagnosis of transplant coronary artery disease (TCAD) was defined as a new > or =50% diameter narrowing of a major epicardial vessel. RESULTS Donor lesions were present in 30% of the hearts. By IVUS, sites with donor lesions did not have a greater increase in intimal area compared with sites without donor lesions. Angiographically, the incidence of TCAD up to three years after transplantation was higher in recipients with donor lesions than in recipients without donor lesions (25% vs. 4%, p < 0.001). However, the three-year mortality rate was similar between recipients with or without donor lesions (4.5% vs. 5.2%, p = 1.0). CONCLUSIONS Pre-existing donor lesions do not act as a nidus for accelerating the progression of intimal hyperplasia. However, patients with donor lesions have a higher incidence of angiographic TCAD. Donor lesions do not affect the long-term survival of patients with OHT up to three years.
Collapse
Affiliation(s)
- Haiyan Li
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | | | | | | | | | | | | |
Collapse
|
12
|
|
13
|
Boyajian RA, Otis SM. Relationship of Lumen Diameter to Type and Degree of Arterial Remodeling at Sites of Expanding Wall or Plaque Thickness in Human Carotid Artery. Cerebrovasc Dis 2003; 17:228-37. [PMID: 14707427 DOI: 10.1159/000075928] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2003] [Accepted: 09/11/2003] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Arterial remodeling exhibits a bidirectional capacity. Whether lumen size affects remodeling response to lesion change is unknown. METHODS Prospective study by duplex ultrasonography over 2 years in 61 subjects with coronary artery disease. Direction and magnitude of vessel remodeling are calculated for internal carotid, bifurcation, and common carotid artery segments. RESULTS A linear trend is discernible between lumen diameter and direction and magnitude of remodeling at sites of expanding intima-media thickness (IMT) or plaque. Rate of lesion change varied inversely with lesion thickness with an inflection between rates for low-dimension IMT and plaque. CONCLUSIONS Dilatation versus shrinkage in the remodeling response to expanding lesions appears related to lumen size. IMT and plaque exhibit independent biologies.
Collapse
Affiliation(s)
- Robert A Boyajian
- Department of Medicine, Division of Neurology, Center for Brain Research and Treatment, Scripps Clinic, La Jolla, Calif., USA
| | | |
Collapse
|