AORTIC-ANEURYSM IN HEART-TRANSPLANT RECIPIENTS

Purpose: The purpose of this study was to define the clinical features of aortic aneurysms occurring in heart transplant recipients. Methods : Among the 734 patients who have undergone heart transplantation at o ur institution over the last 14 years, we have identified 12 patients (1.6% incidence) with aortic aneurysms (9 infrarenal, 3 thoracoabdomin al), making this the largest reported series of aortic aneurysms (AA) in heart transplant recipients. Results: For nine of the 12 patients w ith AA (75%), the indication for transplantation was ischemic cardiomy opathy. This indication accounted for only 42% of the overall transpla ntation group; our data therefore show that the risk of infrarenal AA disease was higher for patients who underwent transplantation for isch emic cardiomyopathy than for other indications (p = 0.02). In two of t he patients with thoracoabdominal AA, chronic dissection was identifie d as the specific AA cause, whereas all of the other patients in the s tudy had nonspecific ((atherosclerotic)) AAs. All 12 patients were sym ptom free at the time of initial discovery of the AAs. Two of the pati ents with infrarenal AA were diagnosed with AAs before transplantation ; for the seven remaining patients with infrarenal AAs, the mean time between transplantation and AA discovery was 5.0 years (range 1.2 to 1 1.8 years). Serial radiologic studies allowed us to determine the AA e xpansion rate in seven of the 12 patients. This rate varied from 0 to 2.53 cm/yr (mean 1.20 cm/yr; 1.0 cm/yr for infrarenal AA alone). Five patients with infrarenal AA underwent AA repair as the initial treatme nt. Three others underwent repair after their AAs significantly expand ed under observation. Mean AA diameter at the time of repair was 6.9 c m. All three patients with thoracoabdominal AAs died of acute AA ruptu re before resection could be done, despite their initial asymptomatic state. AA diameters at time of rupture were 3.5, 6.0, and 11 cm. All o f the eight patients with AA treated with surgery are alive and well ( median follow-up 18 months). The only complication was acute heart tra nsplant rejection, which occurred 11 days after AA repair in one patie nt. Conclusions: Our data suggest that AA occurrence is more likely in patients who undergo heart transplantation for ischemic heart disease than for other indications. Careful serial radiologic surveillance is warranted in any heart transplant patient with an AA, because of the apparent potential for more rapid AA expansion in this patient populat ion than in patients who do not undergo transplantation. We conclude t hat early repair of infrarenal AA is indicated because excellent opera tive results and low morbidity rates can be achieved. An aggressive ap proach to thoracoabdominal AAs in this group may also be appropriate b ecause of the apparent propensity to lethal rupture, sometimes at rela tively small AA size.