THE MANAGEMENT OF POST-CARDIAC TRANSPLANTATION CORONARY-ARTERY DISEASE

Objective. Allograft coronary artery disease remains the single greate st limitation to long term survival after cardiac transplantation. It is peculiarly aggressive in its behaviour and diffuse in its nature. T he role of conventional approaches to coronary artery revascularisatio n were studied in a selected group of cardiac transplant recipients. M ethods. Of the 557 patients undergoing cardiac transplantation at our unit between January 1979 and December 1993, all were screened for the development of allograft coronary artery disease routinely after 2 ye ars and yearly thereafter or after 4 years. Twenty patients with allog raft coronary artery disease were considered suitable for treatment by conventional means 17 of whom had undergone transplantation for ischa emic cardiomyopathy and the others for dilating cardiomyopathy. Percut aneous transluminal coronary angioplasty was performed in 18, 25-103 m onths after transplantation (mean 60 months) all of whom had severe pr oximal stenoses and reversible defects on perfusion scans. None suffer ed chest pain. Coronary artery bypass grafting was performed in 5, 95- 105 months after transplantation (mean 101 months) 2 of whom had post- infarction unstable angina and 3 had severe triple vessel disease, dys pnoea, and perfusion abnormalities. Results. The primary success rate for PTCA was 84% (16/19). Two lesions restenosed and 3 patients had pr ogressive disease which necessitated coronary revascularisation. No pa tient died. Of the 5 patients undergoing coronary artery surgery 2 di ed perioperatively, one from acute left ventricular failure and one fr om acute rejection. All 18 survivors have improved perfusion scans. Fo llowing surgery, all survivors had improvement in dyspnoea and relief of angina. Five late deaths a mean of 89 months after transplantation were from coronary artery disease (4) and lung malignancy (1). Conclus ions. Revascularisation by PTCA and CABG is feasible and successful in selected cardiac transplant recipients. Further study is required to determine the effect of revascularisation on prognosis.