Long-term outcome of cardiac allograft vasculopathy: Importance of the International Society for Heart and Lung Transplantation angiographic grading scale.

ABSTRACT

BACKGROUND: Cardiac allograft vasculopathy (CAV) is a major complication limiting long-term survival after heart transplantation (HTx). However, long-term outcome data of HTx recipients with detailed information on angiographic severity are scarce. METHODS: The study included 501 HTx recipients with angiographic follow-up up to 20 years post-transplant. All coronary angiograms were classified according to the International Society for Heart and Lung Transplantation (ISHLT) grading scale. RESULTS: CAV prevalence increased over time after transplantation, reaching 10% at 1 year, 44% at 10 years, and 59% at 20 years. Older donor age (hazard ratio [HR] 1.38 per 10 years, 1.20-1.59, p < 0.001), male donor sex (HR 1.86, 1.31-2.64, p < 0.001), stroke as donor cause of death (HR 1.47, 1.04-2.09, p = 0.03), recipient pre-transplant hemodynamic instability (HR 1.79, 1.15-2.77, p = 0.01), post-transplant smoking (HR 1.59, 1.06-2.39, p = 0.03), and first-year treated rejection episodes (HR 1.49, 1.01-2.20, p = 0.046) were independent risk factors for CAV. Baseline anti-metabolite drug use (HR 0.57, 0.34-0.95, p = 0.03) and more recent transplant date (HR 0.78 per 10 years, 0.62-0.99, p = 0.04) were protective factors. Compared with patients without CAV, the HR for death or retransplantation was 1.22 (0.85-1.76, p = 0.28) for CAV 1, 1.86 (1.08-3.22, p = 0.03) for CAV 2, and 5.71 (3.64-8.94, p < 0.001) for CAV 3. CONCLUSIONS: CAV is highly prevalent in HTx recipients and is explained by immunologic and non-immunologic factors. Higher ISHLT CAV grades are independently associated with worse graft survival.