title: Assessment of cardiac allograft vasculopathy late after heart transplantation: when is coronary angiography necessary?
abstract: 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.
authors.affiliation: Department of Internal Medicine I, Center of Cardiovascular Medicine, University of Würzburg, Würzburg, Germany. stoerk_s@klinik.uni-wuerzburg.de
authors.forename: Stefan
authors.initials: S
authors.lastname: Störk
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Behr
authors.forename: Michael
authors.initials: M
authors.lastname: Birk
authors.forename: Peter
authors.initials: P
authors.lastname: Uberfuhr
authors.forename: Volker
authors.initials: V
authors.lastname: Klauss
authors.forename: Christoph H
authors.initials: CH
authors.lastname: Spes
authors.forename: Christiane E
authors.initials: CE
authors.lastname: Angermann
mesh_terms: 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
chemical_list: D000990:Antithrombin III