Prevention and treatment of cardiac allograft vasculopathy
- Howard J Eisen, MD
Howard J Eisen, MD
- Thomas J Vischer Professor of Medicine
- Drexel University College of Medicine
Cardiac transplantation is the definitive therapy for eligible patients with end-stage heart failure. The major limitations to survival in the early (first one year) posttransplant period are nonspecific graft failure, multiorgan failure, acute rejection, and infection [1,2]. Beyond the first year, cardiac allograft vasculopathy (CAV, also called transplant coronary artery disease or cardiac transplant vasculopathy) is among the top three causes of death, after malignancy as shown in the reports of the Registry of the International Society of Heart and Lung Transplantation . (See "Prognosis after cardiac transplantation", section on 'Causes of death'.)
The approach to the prevention and treatment of CAV will be reviewed here. The pathogenesis of allograft vasculopathy is discussed separately. (See "Pathogenesis of and risk factors for cardiac allograft vasculopathy".)
NATURAL HISTORY AND DIAGNOSIS
The natural history and diagnosis of allograft vasculopathy are discussed separately, but the major findings will be reviewed here. (See "Diagnosis and prognosis of cardiac allograft vasculopathy".)
●The heart is denervated at the time of transplant and reinnervation is generally incomplete. As a result, vasculopathy generally progresses silently and, in some cases, rapidly. Because of afferent denervation, affected patients seldom present with classic symptoms of angina. Silent myocardial infarction, sudden death, and progressive heart failure are common presentations. Symptoms associated with exertion, such as dyspnea, diaphoresis, gastrointestinal distress, presyncope, or syncope, are often infrequent, atypical, and may be misleading.
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- NATURAL HISTORY AND DIAGNOSIS
- - Other lipid-lowering drugs
- Everolimus and sirolimus
- - Everolimus
- - Sirolimus
- Mycophenolate mofetil
- Antioxidant vitamins
- Changes in immunosuppression
- - Augmented immunosuppression
- - Sirolimus
- Percutaneous coronary intervention
- Coronary artery bypass graft
- Prophylactic ICD
- SUMMARY AND RECOMMENDATIONS