Coronary artery bypass grafting after orthotopic heart transplantation

Objective: Graft coronary disease (GCD) remains the major determinant of lo ng-term survival after heart transplantation. Therapeutic strategies for th e prevention or retardation of GCD in the cardiac allograft are limited, an d palliative surgical coronary revascularization has been attempted. The ai m of this report was to retrospectively analyze our results of coronary art ery bypass grafting after cardiac transplantation. This paper correlates th e outcome of patients with the pathohistological and angiographic type of l esion in order to identify transplant recipients who may profit from surgic al myocardial revascularization. Methods: Seven patients with a mean age of 55 years (range 45-61 years) underwent coronary artery bypass grafting as a result of GCD at a mean of 67 months (range 6-128 months) after cardiac t ransplantation. By the inclusion of the clinical history and the angiograph ic pattern of GCD lesions, the primary indications for surgical revasculari zation, operative results, pathohistological studies and follow-ups were ex amined. Results: Elective surgery was performed in two patients with proxim al, severe triple vessel disease (Type A lesion) and in one patient in whom the primary reason for cardiac surgery was severe tricuspid regurgitation. This patient electively received a tricuspid valve replacement and concomi tant single Vessel bypass surgery for proximal GCD (Type A lesion). Emergen cy surgery was performed in four patients: preoperatively three patients po st-infarction developed worsening congestive heart failure, which resulted in low cardiac output syndrome. One patient with combined Types A and B/C l esions required emergency surgery for dissection of the right coronary arte ry (RCA) after an angioplasty procedure. Angiographically all these patient s showed diffuse, distal arteriopathy (combined Type B/C lesions). The elec tively operated patients (n = 3) and the patient with dissection of the RCA (n = 1) had successful operations and survived beyond hospital discharge ( overall survival for coronary artery bypass graft (CABG) in GCD patients 4 out of 7; 57%). All three patients with distal arteriopathy, who underwent emergency surgery, died in hospital from left ventricular failure (43%). Th e four patients discharged from hospital with a mean follow-up of 10 months (range 2-32 months) are all in good clinical condition. Conclusions: Coron ary artery bypass,grafting can be successfully performed in a subgroup of c ardiac transplant patients with Type A lesions, However, the state of diffu sely diseased distal arteries (Type B/C lesions), which is prevalent in thi s group of patients, limits the use of bypass surgery. (C) 1999 Elsevier Sc ience B,V. All rights reserved.