Coronary angioplasty, bypass surgery, and retransplantation in cardiac transplant patients with graft coronary disease

Background: Graft coronary disease (GCD) remains the single greatest limita tion to long-term survival of heart transplant recipients. Therapeutic stra tegies for the prevention or retardation of CCD in the cardiac allograft ar e limited; palliative coronary revascularization has been attempted. Becaus e of the high mortality rate associated with advanced forms of GCD our inst itution offers the option of retransplanation in selected cases. The aim of I-his study was by analyzing retrospectively the outcomes of angioplasty, coronary bypass grafting, and retransplantation in cardiac transplant patie nts to attempt to identify subgroups of transplant recipients with graft co ronary disease who may profit from myocardial revascularization. Methods: O f the 989 patients undergoing 1016 heart transplantations (HTx) at our inst itution between 10/86 and 12/97 all were screened for the development of GC D. Analyzing routinely annual angiography, intracoronary ultrasound in defi ned study patients, and autopsy Findings, GCD was diagnosed in 124 patients (110 male, 14 female) 2 to 107 months after HTx (mean 30 months). Results: PTCA: Fourty-six out of 124 patients underwent 76 angioplasties ata mean o f 50 +/- 30 months (range 4-91 mo) following cardiac transplantation. The p rimary success rate was 96% (73/ 76). The reason for the unsuccessful angio plasty attempts (n = 3) was failure to completely penetrate a stenosis of L AD in 2 patients and severe dissection of RCA, which required emergency sur gery, in one. Angiographic: restenosis occurred in 42% (31 of 76 lesions) a nd was diagnosed 11 +/- 11 months after the first angioplasty. There was no procedure-related death. CABG: Seven patients underwent bypass surgery at a mean of 67 months (range 6-128 months) after HTx. Elective surgery was pe rformed in 2 patients with proximal severe triple-vessel disease (Type A le sion) and in 1 patient with severe tricuspid regurgitation who received a t ricuspid valve replacement and concomitant single-vessel bypass surgery for proximal GCD (Type A lesion). One patient with combined Type A and BIC les ions required emergency surgery for dissection of RCA after an angioplasty procedure. Three patients with post-infarction unstable angina developed wo rsening congestive heart failure which required emergency surgery. Angiogra phically all these patients showed diffuse, distal arteriopathy (combined T ype Bit lesions). The electively operated patients and the patient with dis section of RCA were successfully treated and survived beyond hospital disch arge (overall survival for CABG in GCD patients 4/7=57%).