Early accelerated cardiac allograft vasculopathy

Excerpt

The development of cardiac allograft vasculopathy remains the Achilles heel of cardiac transplantation. We present the images of a 63-year-old patient with diabetes mellitus, hyperlipidemia, and hypertension that underwent heart transplantation due to ischemic cardiomyopathy in 2011. Preoperatively, the patient was not in any mechanical device support and the total ischemia time was 142 min. Post-transplant, he developed a subclinical cytomegalovirus (CMV) infection that was treated for 4 months with valganciclovir. Later, the post-transplant CMV status was negative with no relapse. In 2015, he was presented with a International Society for Heart and Lung Transplantation (ISHLT) cardiac allograft vasculopathy (CAV) grade 2 [1] (Fig. 1a; total occlusion of the right coronary artery) that progressed after 2 years to ISHLT CAV grade 3 with ejection fraction of 45% (Fig. 1b, severe left main, diagonal branch, and circumflex artery stenosis). He underwent a successful percutaneous coronary intervention (PCI) without intravascular ultrasound (IVUS) assistance with a drug-eluting stent implantation to the left main and diagonal branch (Fig. 1c). During post-transplant follow-up, the endomyocardial biopsies were normal and no antibody-mediated rejection was detected. The post-transplant immunosuppression regiment of the patient was tacrolimus, mycophenolat mofetil (MMF) and prednisone that after 2 years was discontinued. After the right coronary artery lesion diagnosis, MMF was replaced by everolimus. Diltiazem was not added to the treatment. The donor was a 43-year-old male patient without comorbidities and the cause of death was brain bleeding. Donor-specific antibodies and coronary angiogram are not routinely performed. In 2012, the recipient underwent computed tomography (CT) coronary angiogram that was normal. The take-home message is that better management of the cardiac risk factors, mainly the diabetes mellitus, would delay the onset of CAV and may lessen its severity. An informed consent and institutional review board permission were obtained to present these images.

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