Efficacy of augmented immunosuppressive therapy for early vasculopathy in heart transplantation.
OBJECTIVE
The present study was undertaken to prospectively and comparatively evaluate the role of serial myocardial perfusion imaging and coronary angiography for the detection of early vasculopathy in a large patient population and also to determine the short- and long-term efficacy of augmented immunosuppressive therapy in the potential reversal of the early vasculopathy.


BACKGROUND
Allograft vasculopathy is the commonest cause of death after the first year of heart transplantation. Anecdotal studies have reported the efficacy of augmented immunosuppressive therapy after early detection of vascular involvement. However, no prospective study has evaluated the feasibility of early detection and treatment of allograft vasculopathy.


METHODS
In 76 cardiac allograft recipients, 230 coronary angiographic and 376 scintigraphic studies were performed in a follow-up period of 8 years. Angiography was performed at 1 month and every year after transplantation, and thallium-201 scintigraphy at 1, 3, 6 and 12 months after transplantation and twice a year thereafter. Prospective follow-up of 76 patients showed that 18 developed either angiographic or scintigraphic evidence of coronary vasculopathy. All episodes were treated with 3-day methylprednisolone pulse and antithymocyte globulin.


RESULTS
Twenty-two episodes of vasculopathy were diagnosed and treated in these 18 patients. Of these 22 episodes, two were detected only by angiography, seven by both angiography and scintigraphy, four by scintigraphy and histologic evidence of vasculitis and nine episodes only by thallium-201 scintigraphy studies. Angiographic and/or scintigraphic resolution was observed in 15 of the 22 episodes (68%) with augmented immunosuppression. The likelihood of regression was higher when treatment was instituted within the first year of transplantation (92%) than after the first year (40%) (p = 0.033). Eighty percent of patients who responded to follow-up.


CONCLUSIONS
The present study suggests that early detection of allograft coronary vasculopathy is feasible with surveillance myocardial perfusion or coronary angiographic studies. When identified early after transplantation, immunosuppressive treatment may result in regression of coronary disease.
Lamich
R
R
Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
Ballester
M
M
Martí
V
V
Brossa
V
V
Aymat
R
R
Carrió
I
I
Bernà
L
L
Campreciós
M
M
Puig
M
M
Estorch
M
M
Flotats
A
A
Bordes
R
R
Garcia
J
J
Augè
Padró
J M
JM
Caralps
J M
JM
Narula
J
J
D000328:Adult; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage / Q000627:therapeutic use; D000961:Antilymphocyte Serum / Q000008:administration & dosage / Q000627:therapeutic use; D002423:Cause of Death; D002648:Child; D017023:Coronary Angiography; D003326:Coronary Circulation / Q000187:drug effects; D003327:Coronary Disease / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000517:prevention & control*; D005069:Evaluation Studies as Topic; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D005938:Glucocorticoids / Q000008:administration & dosage / Q000627:therapeutic use; D016027:Heart Transplantation; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D008297:Male; D008775:Methylprednisolone / Q000008:administration & dosage / Q000627:therapeutic use; D008875:Middle Aged; D011446:Prospective Studies; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D013794:Thallium Radioisotopes; D013997:Time Factors; D014657:Vasculitis / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000517:prevention & control
D000893:Anti-Inflammatory Agents; D000961:Antilymphocyte Serum; D005938:Glucocorticoids; D007166:Immunosuppressive Agents; D019275:Radiopharmaceuticals; D013794:Thallium Radioisotopes; D008775:Methylprednisolone