title: Heterogeneity of cardiac allograft vasculopathy: clinical insights from coronary angioscopy.
abstract: OBJECTIVE
  With this study, we sought to examine the heterogeneity of cardiac allograft vasculopathy in vivo using coronary angioscopy as an adjunct to intravascular ultrasound, and we evaluated the clinical relations of immunologic and nonimmunologic risk factors with the different forms of cardiac allograft vasculopathy detected angioscopically.
  
  
  BACKGROUND
  Intravascular ultrasound detects vascular intimal proliferation accurately but is limited in its ability to delineate morphologic characteristics. Coronary angioscopy can evaluate intimal surface morphology by direct visualization and can differentiate pathologically distinct forms of plaque topography on the basis of color and contour.
  
  
  METHODS
  We studied 107 consecutive heart transplant recipients with intravascular ultrasound and angioscopy at the time of their annual angiogram, and we assessed the relation of nonimmunologic and immunologic risk factors to the development of cardiac allograft vasculopathy distinguished angioscopically into a pigmented (yellow) or nonpigmented (white) intimal thickening. We further evaluated the clinical differences in cardiac events among these two forms of angioscopically heterogeneous forms of cardiac allograft vasculopathy.
  
  
  RESULTS
  Significant clinical predictors of nonpigmented intimal thickening were advanced donor age and lower mean cyclosporine levels, whereas hyperlipidemia, cumulative prednisone dose and time since transplantation correlated with pigmented intimal hyperplasia. In addition, comparisons between the two angioscopic groups revealed increased intimal thickening, serum cholesterol, low density lipoprotein cholesterol, acute allograft rejection and time since transplantation in the group with pigmented intimal thickening (p < 0.05). With regard to cardiac events, nonpigmented plaque was more frequently found in the sudden death group (53% vs. 20%, p = 0.05), whereas the nonsudden cardiac event group had a significantly higher prevalence of pigmented plaque (80% vs. 47%, p = 0.07).
  
  
  CONCLUSIONS
  These findings indicate that cardiac allograft vasculopathy is a heterogeneous disease with varied morphologic expressions with different clinical implications. Furthermore, this investigation provides insight into the cohesive, yet diverse influences of various factors, particularly immunosuppression, in these forms of cardiac allograft vasculopathy.
authors.affiliation: Department of Internal Medicine, Ochsner Medical Institutions, New Orleans, Louisiana 70121, USA.
authors.forename: M R
authors.initials: MR
authors.lastname: Mehra
authors.forename: H O
authors.initials: HO
authors.lastname: Ventura
authors.forename: S P
authors.initials: SP
authors.lastname: Jain
authors.forename: K
authors.initials: K
authors.lastname: Ramireddy
authors.forename: A
authors.initials: A
authors.lastname: Ali
authors.forename: D D
authors.initials: DD
authors.lastname: Stapleton
authors.forename: F W
authors.initials: FW
authors.lastname: Smart
authors.forename: S R
authors.initials: SR
authors.lastname: Ramee
authors.forename: T J
authors.initials: TJ
authors.lastname: Collins
authors.forename: C J
authors.initials: CJ
authors.lastname: White
mesh_terms: D000328:Adult; D017546:Angioscopy; D003327:Coronary Disease / Q000000981:diagnostic imaging / Q000209:etiology* / Q000473:pathology; D003331:Coronary Vessels / Q000000981:diagnostic imaging / Q000473:pathology*; D016757:Death, Sudden, Cardiac / Q000453:epidemiology / Q000209:etiology; D005260:Female; D006084:Graft Rejection / Q000150:complications; D016027:Heart Transplantation / Q000009:adverse effects*; D006801:Humans; D006965:Hyperplasia / Q000473:pathology; D007165:Immunosuppression Therapy / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D010858:Pigmentation; D012307:Risk Factors; D017539:Tunica Intima / Q000473:pathology; D018084:Ultrasonography, Interventional