Cardiac transplant vasculopathy

Study objective: Coronary allograft vasculopathy (CAV) remains the major fa ctor limiting long-term survival after heart transplantation. The purpose o f this article is to review for the nontransplant physician the concept of CAV as a disease entity after heart transplantation. Design: A MEDLINE search from 1985 to 1999 was performed. Data on cardiac t ransplant vasculopathy were divided into pathology, pathophysiology, presen tation, diagnosis, and treatment. Results: CAV manifests as a unique and unusually aggressive form of coronar y artery disease that differs from traditional atherosclerosis. It is belie ved to be caused by immunologic mechanisms that combine with nonimmunologic factors to cause endothelial injury, resulting in smooth muscle proliferat ion and intimal thickening. This intimal hyperplasia leads to coronary obst ruction, which ultimately results in allograft failure. Diagnosis of CAV ca n be difficult because transplant recipients have denervated hearts and rar ely present with chest pain. Various noninvasive screening methods have not proved reliable. Therefore, most transplant centers perform periodic coron ary angiography for routine CAV surveillance. Treatment of CAV involves mod ification of risk factors and the use of pharmacologic agents that alter va scular physiology. Revascularization procedures continue to play a role as palliative therapy, but are limited in their effectiveness by the diffuse n ature of this disease. Conclusion: Cardiac transplant vasculopathy continues to play a major dilem ma regarding posttransplant care. Further research is needed to develop suc cessful preventive and therapeutic strategies that may alter the course of this disease.