title: Long-term mortality after cardiac allograft vasculopathy: implications of percutaneous intervention.
abstract: OBJECTIVE
  This study compared the prognosis of patients with proximal cardiac allograft vasculopathy (CAV) treated with percutaneous intervention (PCI) to the prognosis of those with severe CAV not amenable to PCI.
  
  
  BACKGROUND
  CAV is a progressive form of arterial narrowing affecting patients with orthotopic heart transplants (OHTs). PCI has been used to treat patients with focal CAV, but its efficacy remains unclear.
  
  
  METHODS
  Of 853 patients undergoing OHT and subsequent coronary angiographies at the Cleveland Clinic, all patients with at least moderate CAV (>30%) on any coronary angiogram following OHT were included. Of remaining patients with no/mild CAV, 200 patients were randomly chosen to represent the comparison group. All angiograms of the included patients were reviewed and graded according to the International Society of Heart and Lung Transplantation (ISHLT) nomenclature.
  
  
  RESULTS
  Of the 393 included patients, 100 patients underwent definitive intervention for CAV. Of these 100 patients, 90 patients underwent PCI only, 6 patients underwent coronary artery bypass grafting, and 4 patients underwent repeat OHT. We observed a progressive increase in long-term mortality with worsening CAV. Patients with ISHLT grade 3 CAV had the highest long-term mortality compared with other groups. In addition, there was a significant reduction in the risk for mortality at 2-year follow-up (adjusted odds ratio: 0.26; 95% confidence interval [CI]: 0.08 to 0.82) and 5-year follow-up (adjusted odds ratio: 0.28; 95% CI: 0.09 to 0.93) after PCI compared with patients diagnosed with ISHLT grade 3 CAV, who were deemed unsuitable for PCI. Furthermore, statin use was associated with a significant survival benefit in patients with CAV (hazard ratio: 0.21; 95% CI: 0.07 to 0.61).
  
  
  CONCLUSIONS
  Worsening severity of CAV was associated with progressively worse long-term survival among heart transplant recipients. Among patients with CAV, long-term survival in those with CAV amenable to PCI was greater than that in those with severe CAV not treatable with PCI.
authors: Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors: Shikhar
authors: S
authors: Agarwal
authors: Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors: Akhil
authors: A
authors: Parashar
authors: Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors: Samir R
authors: SR
authors: Kapadia
authors: Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors: E Murat
authors: EM
authors: Tuzcu
authors: Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors: Dhruv
authors: D
authors: Modi
authors: Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors: Randall C
authors: RC
authors: Starling
authors: Advanced Heart Failure and Transplantation Center and Onco-Cardiology Center, Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio. Electronic address: guilherme.oliveira@uhhospitals.org.
authors: Guilherme H
authors: GH
authors: Oliveira
mesh_terms: D015331:Cohort Studies; D017023:Coronary Angiography / Q000401:mortality; D023921:Coronary Stenosis / Q000209:etiology / Q000401:mortality* / Q000601:surgery; D018450:Disease Progression; D005260:Female; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000401:mortality* / Q000601:surgery; D016027:Heart Transplantation / Q000379:methods / Q000401:mortality*; D006801:Humans; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000401:mortality*; D011379:Prognosis; D012086:Reoperation / Q000401:mortality; D014184:Transplantation, Homologous / Q000401:mortality
keywords: cardiac allograft vasculopathy; coronary artery disease; orthotopic heart transplantation; percutaneous intervention