Prognosis of moderate coronary artery lesions in heart transplant patients.

BACKGROUND: Despite recent advances in our understanding of allograft vasculopathy, little is known about the evolution of moderate coronary lesions in heart transplant recipients. METHODS: We retrospectively analyzed 58 heart transplant patients undergoing annual coronary angiography who demonstrated a moderate lesion (>30% and <60% diameter stenosis) on any routine annual study. In an attempt to find criteria that could distinguish such patients who were at high risk of disease progression from those at low risk, we reviewed the clinical and biologic features and angiographic and clinical outcomes of patients with and without lesion progression at 1 year. RESULTS: Of the 58 patients who had an initially moderate coronary lesion, 28 (48%) showed progression of the lesion at angiography 1 year later (occlusion of the culprit vessel or progression to a severe lesion >60%) that required revascularization (angioplasty or bypass surgery). The 30 remaining patients showed no lesion progression. At the time of the first angiogram the only criterion which could predict lesion progression at 1 year was the presence of multi-vessel disease (p < 0.0001). Prognosis for these patients was poorer than in those with no disease progression, with a higher proportion of revascularization and sudden death (p < 0.001). Patients without lesion progression at 1 year had neither clinical events nor significant subsequent lesion progression during a mean follow-up of 6 years. CONCLUSIONS: The presence of a moderate coronary stenosis in heart transplant patients justifies a repeat angiogram 1 year later. The use of percutaneous coronary angioplasty in such patients has not been validated, but may be an option to delay or prevent progression to coronary occlusion.

Monitoring of human cytomegalovirus infections in heart transplant recipients by pp65 antigenemia.

BACKGROUND: Rapid diagnostic techniques offer the opportunity of early diagnosis of human cytomegalovirus (CMV) infection in immunocompromized patients at risk of developing CMV disease and syndrome. The use of CMV pp65 antigenemia as a predictor of CMV syndrome and disease in heart transplant recipient after induction therapy was studied retrospectively. METHODS: One hundred and nineteen consecutive heart transplant recipients treated with induction therapy who survived more then 14 d were monitored for CMV infection. Ninety-four recipients were seropositive for CMV. Twenty-five recipients were seronegative for CMV and received grafts from seropositive donors. Pre-emptive therapy was used in seropositive patients when CMV pp65 antigenemia was greater than 50 antigen-positive cells per 2 x 10(5) peripheral blood leukocytes (PBL); prophylactic therapy was done only in seronegative recipient matched with seropositive donor. RESULTS: High-level CMV pp65 antigenemia (50 antigen-positive cells 2 x 10(5) PBL) occurred in 34% (41 of 119) of patients at a median of 44 d following transplantation. In seropositive recipients, 16% (15 of 94) of patients developed CMV invasive disease or syndrome, and in seronegative recipients 20% (5 of 25) of patients developed CMV disease or syndrome. Sixty-six per cent (62 of 94) of CMV seropositive patients were identified as not requiring pre-emptive therapy. In seropositive and seronegative recipients, the sensibility and negative predictive value of the cut-off level of 50 antigen positive cell for CMV disease and syndrome was 100%. The specificity was 79% and positive predictive value was 49%. CONCLUSION: Because of the excellent sensibility and negative predictive value of the cut-off level of 50 antigen positive cell per 2 x 10(5) PBL, application of pre-emptive therapy guided by high level of CMV pp65 antigenemia in the context of induction therapy allow to omit antiviral therapy in many at risk patients. In the context of pre-emptive and prophylactic therapy, the cut-off level of 50 antigen positive cell do not allow to predict with accuracy the development of CMV disease or syndrome.

Myocardial infarction after endomyocardial biopsy in a heart transplant patient.

In a heart transplant patient who had undergone several endomyocardial biopsies, ultrasound examination revealed severe left ventricular dysfunction after a stroke. Coronary angiography showed a distal left anterior descending artery fistula to the right ventricle. Left ventricular angiogram showed apical dyskinesia. The electrocardiogram and angiographic changes were thought to be due to a myocardial infarction secondary to a postendomyocardial biopsy hematoma, which should be added to the list of possible complications involved in endomyocardial biopsy.