HETEROGENEITY OF CARDIAC ALLOGRAFT VASCULOPATHY - CLINICAL INSIGHTS FROM CORONARY ANGIOSCOPY

Objectives. With this study, we sought to examine the heterogeneity of cardiac allograft vasculopathy in vivo using coronary angioscopy as a n adjunct to intravascular ultrasound, and we evaluated the clinical r elations of immunologic and nonimmunologic risk factors with the diffe rent forms of cardiac allograft vasculopathy detected angioscopically. Background. Intravascular ultrasound detects vascular intimal prolife ration accurately but is limited in its ability to delineate morpholog ic characteristics. Coronary angioscopy can evaluate intimal surface m orphology by direct visualization and can differ entiate pathologicall y distinct forms of plaque topography on the basis of color and contou r. Methods. We studied 107 consecutive heart transplant recipients wit h intravascular ultrasound and angioscopy at the time of their annual angiogram, and we assessed the relation of nonimmunologic and immunolo gic risk factors to the development of cardiac allograft vasculopathy distinguished angioscopically into a pigmented (yellow) or nonpigmente d (white) intimal thickening. We further evaluated the clinical differ ences in cardiac events among these two forms of angioscopically heter ogeneous forms of cardiac allograft vasculopathy. Results. Significant clinical predictors of nonpigmented intimal thickening were advanced donor age and lower mean cyclosporine levels, whereas hyperlipidemia, cumulative prednisone dose and time since transplantation correlated w ith pigmented intimal hyperplasia. In addition, comparisons between th e two angioscopic groups revealed increased intimal thickening, serum cholesterol, low density lipoprotein cholesterol, acute allograft reje ction and time since transplantation in the group with pigmented intim al thickening (p < 0.05). With regard to cardiac events, nonpigmented plaque was more frequently found in the sudden death group (53% vs. 20 %, p = 0.05), whereas the nonsudden cardiac event group had a signific antly higher prevalence of pigmented plaque (80% vs. 47%, p = 0.07). C onclusions. These findings indicate that cardiac allograft vasculopath y is a heterogeneous disease with varied morphologic expressions with different clinical implications. Furthermore, this investigation provi des insight into the cohesive, yet diverse influences of various facto rs, particularly immunosuppression, in these forms of cardiac allograf t vasculopathy. (C) 1997 by the American College of Cardiology.