Cardiac allograft vasculopathy medical therapy: Difference between revisions

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==Overview==
==Overview==
Once CAV has developed, pharmacologic options to halt progression are limited. Retransplantation is the only definitive treatment of established CAV. Ideal regimen should not affect the lipid profile, blood pressures and renal function, and have a positive impact on hemodynamics.
==Medical Therapy==
==Medical Therapy==
===Pharmacologic Management===
===Pharmacologic Management===

Revision as of 20:36, 14 December 2014

Cardiac allograft vasculopathy Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2]; Raviteja Guddeti, M.B.B.S. [3]

Overview

Once CAV has developed, pharmacologic options to halt progression are limited. Retransplantation is the only definitive treatment of established CAV. Ideal regimen should not affect the lipid profile, blood pressures and renal function, and have a positive impact on hemodynamics.

Medical Therapy

Pharmacologic Management

Nonpharmacologic Interventions

Retransplantation

  • Retransplantation is the only definitive treatment for CAV. It is associated with satisfactory survival in patients with CAV.
  • About 60% of the repeat transplantation procedures performed are due to graft failure secondary to CAV [1]. It is a higher risk procedure and raises significant ethical concerns primarily because of scarcity of heart transplant donors [2].
  • Prognosis: One year survival has improved in recent years, but continues to be inferior compared to primary transplants (79% in re-transplant group compared to 85% in primary transplant group) [3].

Percutaneous Coronary Intervention

  • This procedure is limited only to a selected group of patients with focal disease in a single artery. Moreover, the number of patients who benefit are small.
  • Incidence of re-stenosis is high, ranging from 20 to 60% as reported in various studies.
  • Intracoronary stenting appears to have lower rate of re-stenosis as compared to coronary angioplasty alone.
  • Concomitant use of high dose immunosuppressive therapy with azathioprine and mycophenolate have shown to significantly reduce the rate of re-stenosis [4].

Coronary Artery Bypass Grafting

  • Associated with a high perioperative mortality especially in those with distal disease.
  • In a retrospective analysis of 12 patients with CAV who underwent CABG, 4 died perioperatively, while only 7 were alive at the end of 9 months post-surgery [5].

Transmyocardial Revascularization

  • Also known as transmyocardial laser revascularization (TMLR), is a procedure involving creation of transmural channels in the myocardium to enhance blood supply.
  • This procedure has been studied in multiple clinical trials in patients with refractory angina and those who are not considered as surgical candidates.
  • Mehra and colleagues [6] first studied the effects of TMLR in patients with diffuse CAV. They reported significant improvement in symptoms and anginal class at 4 and 8 week follow up. However, at 24 month follow up, the procedure showed neither consistent symptomatic improvement nor any change in course of the progression of CAV [7].

Heparin Induced/Mediated Extracorporeal LDL Plasmapheresis

  • Also known as LDL apheresis.
  • Leads to significant reductions in LDL, lipoprotein(a) levels and fibrinogen.
  • No effect on HDL levels.
  • In a prospective study by Park et al., patients treated with LDL apheresis had a statistically significant increase in intraluminal diameter between 1 year and 2.5 years of follow up. However, long term trials are required to draw firm conclusions.

References

  1. Mehra MR (2006). "Contemporary concepts in prevention and treatment of cardiac allograft vasculopathy". Am J Transplant. 6 (6): 1248–56. doi:10.1111/j.1600-6143.2006.01314.x. PMID 16686747.
  2. Radovancevic B, McGiffin DC, Kobashigawa JA, Cintron GB, Mullen GM, Pitts DE; et al. (2003). "Retransplantation in 7,290 primary transplant patients: a 10-year multi-institutional study". J Heart Lung Transplant. 22 (8): 862–8. PMID 12909465.
  3. Srivastava R, Keck BM, Bennett LE, Hosenpud JD (2000). "The results of cardiac retransplantation: an analysis of the Joint International Society for Heart and Lung Transplantation/United Network for Organ Sharing Thoracic Registry". Transplantation. 70 (4): 606–12. PMID 10972218.
  4. Benza RL, Zoghbi GJ, Tallaj J, Brown R, Kirklin JK, Hubbard M; et al. (2004). "Palliation of allograft vasculopathy with transluminal angioplasty: a decade of experience". J Am Coll Cardiol. 43 (11): 1973–81. doi:10.1016/j.jacc.2004.02.045. PMID 15172400.
  5. Halle AA, DiSciascio G, Massin EK, Wilson RF, Johnson MR, Sullivan HJ; et al. (1995). "Coronary angioplasty, atherectomy and bypass surgery in cardiac transplant recipients". J Am Coll Cardiol. 26 (1): 120–8. PMID 7797740.
  6. Malik FS, Mehra MR, Ventura HO, Smart FW, Stapleton DD, Ochsner JL (1997). "Management of cardiac allograft vasculopathy by transmyocardial laser revascularization". Am J Cardiol. 80 (2): 224–5. PMID 9230169.
  7. Mehra MR, Uber PA, Prasad AK, Park MH, Scott RL, McFadden PM; et al. (2000). "Long-term outcome of cardiac allograft vasculopathy treated by transmyocardial laser revascularization: early rewards, late losses". J Heart Lung Transplant. 19 (8): 801–4. PMID 10967275.

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