Transplant coronary artery disease in children

Transplant coronary artery disease is an accelerated vasculopathy that occu rs in adult and pediatric heart transplant recipients, and it is a leading cause of death among late survivors. This form of coronary disease, also kn own as graft coronary disease, differs from classical atherosclerosis in bo th histologic and angiographic features and it progresses much more rapidly . Although its pathogenesis has not been determined precisely, both immune and non-immune mechanisms appear to contribute, with a final common pathway of endothelial injury due to both antigen-dependent and antigen-independen t factors. Many investigators believe both cellular and/or humoral rejectio n play a direct role in its etiology. In children the true incidence of the condition is unknown, although a multicenter survey identified 58 (7.2%) p atients among 815 transplant recipients at 17 centers. Detection remains di fficult. In the past, non-invasive methods have been unsatisfactory, althou gh recent experience has suggested that Dobutamine stress echocardiography may be promising. Once a diagnosis is made, treatment has been limited to p alliation by either intracoronary interventional procedures or surgical cor onary bypass grafting, and to cardiac retransplantation with its own set of problems. Current efforts are directed at prevention. Blood levels of chol esterol have been reduced in adults treated with Pravastatin, but there hav e been no reports of its use in children. In adults additional agents with potential benefit have included calcium channel blockers and ACE inhibitors . A multicenter trial in children is needed to answer the many remaining qu estions regarding transplant coronary disease in this age group. (C) 2000 E lsevier Science Ireland Ltd. All rights reserved.