Cardiac Allograft Vasculopathy in Pediatric Heart Transplant Recipients: Coronary Stenting as a Prognostic Indicator

Abstract

Purpose: Cardiac allograft vasculopathy (CAV) after heart transplantation (HTx) is a major cause of graft loss with limited treatment options available. Intervention via percutaneous coronary artery stent placement is an option for discrete areas of severe stenosis. We hypothesize that patients with intervenable coronary artery lesions have improved post-CAV diagnosis survival compared to those with non-intervenable lesions. Methods: All pediatric (< 18y) HTx recipients at our institution between 1986-2015 made up the study cohort. Subjects with high-grade (grade 3-4) CAV were stratified by coronary stent placement. Freedom from death or re-transplantation was compared between groups using the log rank test via the Kaplan Meier method. Results: Five-hundred twelve who children underwent HTx, receiving 555 total grafts, were included. One-hundred twenty-one (22%) were later diagnosed with CAV. The median age at CAV diagnosis was 12.6y (IQR 7.7, 16.9). The median time from HTx to CAV onset was 7.7y (IQR 5.0, 11.6). Freedom from CAV at 5 and 10 years post-HTx was 94% and 80%, respectively (Fig 1a). Post-HTx graft survival was worse for those diagnosed with CAV (p< 0.01; Fig 1b). Twelve patients (10% of those with CAV) required a coronary intervention. Post-CAV diagnosis graft survival was higher in CAV patients with intervenable stent lesions (5y survival of 52% vs. 16%, p= 0.02; Fig 1c). Conclusion: Patients with coronary lesions that are amenable to stenting have improved survival compared to patients with coronary lesions not amenable to stenting. However, long-term survival in these patients remains poor (52% survival 5y after diagnosis) and listing for re-transplantation may be indicated for many. (Figure Presented).