REVASCULARIZATION PROCEDURES IN PATIENTS WITH TRANSPLANT CORONARY-ARTERY DISEASE

Objective: To assess the efficacy of revascularization in cardiac tran splant patients who developed de novo coronary artery disease. Methods : Eighteen patients underwent one or more of four methods of revascula rization: percutaneous transluminal coronary angioplasty (PTCA), percu taneous transluminal coronary rotational atherectomy (PTCRA), coronary artery bypass grafting (CABG), and transmyocardial laser revaculariza tion (TMLR). Eleven PTCA procedures were performed in 10 patients 55.3 +/- 6.6 months after transplantation. Six patients underwent PTCRA 83 .3 +/- 11.2 months after transplantation. Five patients underwent CABG 54.0 +/- 12.6 months after transplantation; the mean left ventricular ejection fraction was 49.6 +/- 16.9 (20-65%); hypertrophy was present in two of these patients. One patient with distal coronary artery dis ease and New York Heart Association class IV symptoms underwent TMLR o nly. One patient underwent both CABG and TMLR because of triple Vessel proximal disease, diffuse distal disease, and New York Heart Associat ion class IV symptoms. Results: PTCA was successful in 10 procedures w ith decrease in mean stenosis from 87.7 +/- 2.7 to 24.3 +/- 6.0%. Foll ow-up, at 16.9 +/- 4.0 months, showed restenosis in two patients. PTCR A was successful in all patients with a decrease in mean stenosis from 83.4 +/- 4.4 to 11.7 +/- 1.9%. Short-term follow-up did not reveal re occlusion. Two CABG patients who had hypertrophy died of heart failure 2 and 9 days after their operations. One CABG patient with excellent cardiac function died after 15 days because of pulmonary failure. In o ne patient, left ventricular ejection fraction improved from 35 to 50% , and he is alive 64 months later. Six months after TMLR, the New York Heart Association class in one patient improved from IV to II, and hi s left ventricular ejection fraction improved from 29 to 42%. The ejec tion fraction in the patient who underwent both CABG and TMLR improved from 20 to 56%, but the patient expired 7 weeks later, Conclusions: I t appears that revascularization procedures can be effective in patien ts with coronary artery disease after cardiac transplantation and that coronary angioplasty or atherectomy would be a therapy of choice for single proximal lesions. CABG should be used cautiously and only reser ved for patients with multi-vessel disease without hypertrophy. Laser revascularization with or without bypass grafting has potential to bec ome the therapy of choice for transplant coronary artery disease. (C) 1997 Elsevier Science B.V.