EFFICACY OF AUGMENTED IMMUNOSUPPRESSIVE THERAPY FOR EARLY VASCULOPATHY IN HEART-TRANSPLANTATION

Objectives. The present study was undertaken to prospectively and comp aratively evaluate the role of serial myocardial per fusion imaging an d coronary angiography for the detection of early vasculopathy in a la rge patient population and also to determine the short- and long-term efficacy of augmented immunosuppressive therapy in the potential rever sal of the early vasculopathy. Background. Allograft vasculopathy is t he commonest cause of death after the first year of heart transplantat ion. Anecdotal studies have reported the efficacy of augmented immunos uppressive therapy after early detection of vascular involvement. Howe ver, no prospective study has evaluated the feasibility of early detec tion and treatment of allograft vasculopathy. Methods. In 76 cardiac a llograft recipients, 230 coronary angiographic and 376 scintigraphic s tudies were performed in a follow-up period of 8 years. Angiography wa s performed at 1 month and every pear after transplantation, and thall ium-201 scintigraphy at 1, 3, 6 and It months after transplantation an d twice a year thereafter, Prospective follow up of 76 patients showed that 18 developed either angiographic or scintigraphic evidence of co ronary vasculopathy. All episodes were treated with 3-day methylpredni solone pulse and antithymocyte globulin. Results. Twenty-two episodes of vasculopathy were diagnosed and treated in these 18 patients. Of th ese 22 episodes, tffo were detected only by angiography, seven by both angiography and scintigraphy, four by scintigraphy and histologic evi dence of vasculitis and nine episodes only by thallium-201 scintigraph y studies. Angiographic and/or scintigraphic resolution was observed i n 15 of the 22 episodes (68%) with augmented immunosuppression. The li kelihood of regression was higher when treatment was instituted within the first year of transplantation (92%) than after the first gear (40 %) (p = 0.033). Eighty percent of patients who responded to follow-up. Conclusions. The present study suggests that early detection of allog raft coronary vasculopathy is feasible with surveillance myocardial pe rfusion or coronary angiographic studies. When identified early after transplantation, immunosuppressive treatment may result in regression of coronary disease. (C) 1998 by the American College of Cardiology.