Assessment of cardiac allograft vasculopathy late after heart transplantation: when is coronary angiography necessary?
BACKGROUND
Cardiac allograft vasculopathy (CAV) represents a major prognostic factor in long-term survivors of heart transplantation (HTx). Reliable diagnosis of CAV late after HTx is important but remains the domain of invasive techniques such as coronary angiography.


METHODS
To test alternative approaches, 54 consecutive HTx recipients (mean time since HTx: 52 months) were studied with intravascular ultrasound (IVUS), angiography, dobutamine stress echocardiography and immunofluorescence staining against anti-thrombin III (AT-III) in endomyocardial biopsies. Univariate and multivariate predictors as well as receiver-operating-characteristic (ROC) curves of different sets of predictors were calculated.


RESULTS
Using IVUS as reference standard, CAV was present in 80% of subjects. Coronary angiography identified CAV correctly in only 44% of cases. If AT-III staining alone was used as a diagnostic criterion, CAV was correctly identified in 77% of subjects. In a multivariate analysis, only AT-III, donor age and echocardiography at rest emerged as independent predictors of CAV (p < 0.05 for all), yielding an excellent discriminative power.


CONCLUSIONS
With almost equal reliability when compared with IVUS, CAV can be identified using information on donor age, wall motion score at rest and AT-III staining late after HTx. Coronary angiography may be limited to patients with a high probability score and should not be used routinely for surveillance of CAV.
Störk
Stefan
S
Department of Internal Medicine I, Center of Cardiovascular Medicine, University of Würzburg, Würzburg, Germany. stoerk_s@klinik.uni-wuerzburg.de
Behr
Thomas M
TM
Birk
Michael
M
Uberfuhr
Peter
P
Klauss
Volker
V
Spes
Christoph H
CH
Angermann
Christiane E
CE
D000328:Adult; D000367:Age Factors; D000990:Antithrombin III / Q000378:metabolism; D017023:Coronary Angiography; D003331:Coronary Vessels / Q000000981:diagnostic imaging / Q000378:metabolism / Q000503:physiopathology*; D025401:Echocardiography, Stress; D005260:Female; D016027:Heart Transplantation / Q000473:pathology*; D006801:Humans; D007150:Immunohistochemistry; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009206:Myocardium / Q000378:metabolism; D011379:Prognosis; D014019:Tissue Donors; D014184:Transplantation, Homologous / Q000473:pathology; D018084:Ultrasonography, Interventional; D014652:Vascular Diseases / Q000000981:diagnostic imaging* / Q000378:metabolism
D000990:Antithrombin III