Angiographic presentation of coronary artery spasm in heart transplant recipients

Coronary Vasospasm Causing Chest Pain in Early Postoperative Heart Transplantation

Coronary vasospasm is a rare complication after heart transplant. Due to denervation of the donor heart, patients are typically asymptomatic but may present with cardiac arrhythmias or cardiac arrest. We present a patient with a recent heart transplant who experienced chest pain and was found to have coronary vasospasm.

A case report of cardiac allograft vasculopathy complicated with coronary vasospasm: insights from near-infrared spectroscopy, intravascular ultrasound, and optical coherence tomography

Background

Cardiac allograft vasculopathy (CAV) remains a major complication after heart transplantation. Although coronary vasospasm after heart transplantation has occasionally been reported, the association between CAV and coronary vasospasm remains unclear.

Case summary

A 68-year-old male with a history of heart transplantation 21 years ago presented with atypical angina. Coronary angiography demonstrated intermediate stenoses in the proximal and mid left anterior descending artery (LAD) and right posterolateral artery. Intracoronary acetylcholine provocation testing resulted in subtotal occlusion of the coronary arteries bilaterally, which was resolved by nitroglycerine administration, but the intermediate stenoses remained. The stenosis in the proximal LAD was physiologically significant based on fractional flow reserve. The patient was diagnosed with a developed CAV and concomitant coronary vasospasm and treated with percutaneous coronary intervention and nifedipine. Near-infrared spectroscopy and intravascular ultrasound showed a large isoechoic plaque with a low lipidic burden, suggesting a non-atherosclerotic plaque. Optical coherence tomography revealed a layered homogenous plaque, an intravascular imaging finding common in both CAV and coronary vasospasm. A drug-eluting stent dilated the stenosis, and follow-up angiography at 4 months showed no CAV progression.

Discussion

This case highlights the potential association between CAV and coronary vasospasm. Intravascular imaging detected similarities in plaque morphology between CAV and coronary vasospasm, suggesting that coronary vasospasm might contribute to the development of CAV. Although coronary vasospasm may be underdiagnosed in heart transplant recipients due to the lack of symptoms involving the denervated heart, this case showed that appropriate provocation testing may be beneficial for evaluating the cause of CAV.

Intractable right coronary artery spasm in the early postoperative period after heart transplantation: a case report

Coronary artery spasm after heart transplantation is a very rare complication. In one observational study and many anecdotal reports, most cases of coronary artery spasm occurred more than 1 year after surgery and had good outcomes. However, cases of intractable coronary artery spasm during the early postoperative period resulting in fatality are limited. This report presents a case of two cardiac arrests caused by coronary artery spasms within a short period of time after heart transplantation.

Case report - coronary vasospasm in transplanted heart: a puzzling phenomenon

Background

Coronary artery spasm (CAS) is an underdiagnosed disease especially in heart transplant patients, and in those patients the etiology and pathophysiology remain largely unknown, although it has been associated with cardiac allograft vasculopathy or graft rejection.

Case presentation

We report the case of a heart-transplant patient whose cardiac graft experienced two coronary vasospasms: the first before transplantation, and the other at one-month of a postoperative course complicated by primary graft failure.

Conclusion

Our case illustrates that a transplanted heart predisposed with coronary vasospasm may suffer from early relapse in the recipient despite of complete post-surgical autonomic denervation. Exacerbated endothelial dysfunction of the donor heart after transplant, with the addition of systemic factors in the recipient may be involved in the genesis of this puzzling phenomenon.

Emergency percutaneous coronary intervention for left main trunk thrombus following orthotopic heart transplantation

Heart transplantation (HTx) is the gold standard therapy to improve quality and quantity of life in end‐stage heart failure patients. However, recipients are at risk of experiencing allograft rejection and post‐transplant complications, in the acute as well as chronic phase. A 43‐year‐old man with a history of left ventricular non‐compaction underwent orthotopic HTx. On Day 7, transthoracic echocardiography showed a sudden decrease in cardiac function with hypokinesis in a left ventricular anterior wall distribution. Coronary angiography revealed a large thrombus in the left main trunk. With intra‐aortic balloon pump support, emergency percutaneous coronary intervention was performed. Endomyocardial biopsy showed no rejection. A left main trunk thrombus is rare in the early phase after HTx, but it can be a life‐threatening complication. Transthoracic echocardiography is well known to be important in the management of heart transplant recipients, and coronary angiography as well as myocardial biopsy should be considered when left ventricular wall motion is impaired.

Prevalence and Angiographic Characteristics of Coronary Vasospasm Detected at Surveillance Coronary Angiograms Among Patients With Heart Transplants

OBJECTIVES

Coronary vasospasm in heart transplant recipients occurs through various mechanisms. It has been linked to allograft rejection and coronary vasculopathy, which can result in mortality during follow-up. Here, we investigated the prevalence of coronary vasospasm among heart transplant recipients undergoing surveillance coronary angiography procedures.

MATERIALS AND METHODS

This study was prospectively performed at Başkent University Faculty of Medicine by retrospectively analyzing medical information of patients who underwent bicaval heart transplant between 2003 and 2016 and subsequently had coronary angiography to rule out allograft vasculopathy. We analyzed prevalence of coronary vasospasm, affected vessels, underlying vessel properties, and treatment modalities. Coronary vasospasm was defined as transient diffuse or localized luminal narrowing, either spontaneously or catheter-induced, relieved spontaneously or with nitroglycerine.

RESULTS

Forty-one coronary angiography procedures were performed using the standard Judkins technique. Among these, 5 patients showed coronary vasospasm a mean of 2 years after cardiac transplant. All vasospasm episodes involved the left anterior descending artery, with 2 also involving the circumflex artery and 1 involving the right coronary artery. The degree of luminal narrowing ranged from mild to severe. Episodes that involved the left anterior descending artery more often diffusely involved most of the vessel. In 3 patients, vasospasms were recurrent. Three patients had underlying coronary artery disease, which was relieved in 2 patients who progressed by stent implant. Neither ischemic events nor reduction of ejection fraction was observed during follow-up. There were also no occurrences of cellular or humoral rejection or death in any of the patients with vasospasm.

CONCLUSIONS

Coronary vasospasm is common in heart transplant recipients. It may be diffuse or localized and occur spontaneously or because of underlying coronary artery disease. Factors, including allograft vasculopathy, associated with coronary vasospasm remain to be determined, and further related research is needed.

Intraoperative Acute Multivessel Coronary Vasospasm in Cardiac Allograft: A Case Report

We present a patient who developed acute intraoperative cardiac failure requiring open cardiac message immediately after uncomplicated heart transplantation. After successful resuscitation and establishment of extracorporeal membrane oxygenation, coronary angiography showed diffuse multivessel coronary vasospasm, which responded to intracoronary and IV administration of vasodilators. Cardiac function gradually improved and the patient was discharged home after a prolonged hospital course. Cardiac allograft dysfunction associated with coronary vasospasm immediately after heart transplantation has not previously been reported.

Systemic effects of intracoronary nitroglycerin during coronary angiography in children after heart transplantation

Coronary spasm during coronary angiography for vasculopathy in children can be prevented by the intracoronary administration of nitroglycerin. We reviewed the anesthesia and catheterization reports and charts for pediatric transplant recipients who underwent angiography from 2005 through 2010. Correlation analysis was used to study the relation of post-injection systolic blood pressure (SBP) to nitroglycerin dose. Forty-one angiographic evaluations were performed on 25 patients (13 male and 12 female). Mean age was 9.9 ± 3.2 years (range, 3.3-16.1 yr). The mean total dose of nitroglycerin was 2.93 ± 1.60 µg/kg (range, 1-8 µg/kg). There was a significant drop between the baseline SBP (mean, 106 ± 21.6 mmHg) and the lowest mean SBP before nitroglycerin administration (78 ± 13.2, P <0.0001, paired t test). There was no significant additional change in SBP (mean after nitroglycerin administration, 80.7 ± 13.1 mmHg; P = 0.2). There was a significant drop in lowest heart rate between baseline (109 ± 16.5 beats/min) and before nitroglycerin administration (89 ± 14.3 beats/min; P <0.0001, paired t test). There was no significant additional change in heart rate (mean heart rate after nitroglycerin, 84 ± 17.7 beats/min; P = 0.09). There were 2 interventions for SBP before nitroglycerin and 2 after nitroglycerin. One child experienced a transient ST-T-segment change during angiography after nitroglycerin. In the highest dose range, the additional decrease in SBP was 7.2 mmHg (P=0.03). Routine intracoronary nitroglycerin administration in this dose range produced no significant changes in SBP or heart rate in children.

Very late coronary spasm inducing acute myocardial infarction in a heart transplant recipient

: We report coronary angio findings of very late (10-year) coronary spasm inducing acute myocardial infarction with typical chest pain in a heart transplant recipient. Coronary spasm was promptly relieved by intra-coronary infusion of nitrates.

Usefulness and safety of percutaneous coronary interventions for cardiac transplant vasculopathy

Late morbidity and death as a result of progressive coronary vascular obliteration remains a major unsolved problem after orthotopic heart transplantation. Various percutaneous catheter intervention (PCI) methods have been used to treat transplant coronary artery disease (CAD), but few reports have assessed the longitudinal results of these procedures. Of 1,440 cardiac transplant patients at University of California, Los Angeles, Medical Center, treated between 1984 and 2004, 65 patients who had undergone orthotopic heart transplantation underwent PCI on a total of 156 coronary artery lesions because of transplant CAD between July 1993 and August 2004. The procedural success rate was 93%. Angiographic follow-up was available for 42 patients and 101 lesions 9.5 +/- 5.8 months after PCI. The global restenosis rate was 36%. Multivariate analysis was used to assess 49 clinical, angiographic, and immunologic variables per lesion. The use of a cutting balloon increased the risk of restenosis (odds ratio 11.5, p <0.01) and the use of stents decreased the risk of restenosis (odds ratio 0.34, p <0.05) compared with other PCI methods. The restenosis rate with drug-eluting stents was 19%, lower than that with bare metal stents (31%). Of the 65 patients, 20 (31%) died within 1.9 +/- 1.8 years after PCI. The actuarial survival rate was 56% at 5 years after the first PCI. In conclusion, although the restenosis rate after PCI was higher than that in nontransplant patients with CAD, the immediate and long-term results were acceptable in this high-risk population. Despite the intense inflammation associated with transplant CAD, drug-eluting stents appeared to reduce the occurrence of restenosis. Compared with historical controls, PCI may also improve the actuarial survival rate of patients undergoing orthotopic heart transplantation.

Coronary artery vasospasm causing acute myocardial infarction in a heart transplant recipient

The etiology of cardiac allograft vasculopathy is not known, but may be preceded by both endothelial cell and smooth muscle dysfunction of the epicardial coronary arteries. We here report a case of acute, reversible coronary artery vasospasm which caused a myocardial infarction in a cardiac transplant recipient. The patient had a complex post-transplant course, including an episode of severe vascular rejection several months before this presentation. Interestingly, the event was captured in its early stages because the patient presented with chest pain: a rare event because of the denervation of the transplanted heart. Our ability to document the etiology of this patient's myocardial infarction supports the concept that cardiac allograft vasculopathy is a progressive disease that, in its early stages, may include a reversible component of abnormal vasoreactivity.