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CLINICAL STUDIES

Efficacy of augmented immunosuppressive therapy for early vasculopathy in heart transplantation

Rubén Lamich^a, Manel Ballester, MD^a, Vicens Martí^a, Vicens Brossa^a, Rosa Aymat^a, Ignasi Carrió^*, Lluis Bernà^*, Marta Campreciós^a, Mireia Puig^a, Montserrat Estorch^*, Albert Flotats^*, Ramón Bordes, Juan Garcia^a, Josep M. Augè^a, Josep M. Padró^a, Josep M. Caralps^a and Jagat Narula

^a Cardiomyopathy and Heart Transplantation Program, Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
^* Service of Nuclear Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
Department of Pathology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
Cardiac Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA

Manuscript received September 22, 1997; revised manuscript received April 21, 1998, accepted April 29, 1998.

Address for correspondence: Manel Ballester, MD, Cardiomyopathy and Transplantation Program, Hospital de la Santa Creu i Sant Pau, Sant Antoni M. Claret 167, 08025 Barcelona, Spain
ballester.tiana{at}teleline.es

Objectives. The present study was undertaken to prospectively and comparatively evaluate the role of serial myocardial perfusion imaging and coronary angiography for the detection of early vasculopathy in a large patient population and also to determine the short- and long-term efficacy of augmented immunosuppressive therapy in the potential reversal of the early vasculopathy.

Background. Allograft vasculopathy is the commonest cause of death after the first year of heart transplantation. Anecdotal studies have reported the efficacy of augmented immunosuppressive therapy after early detection of vascular involvement. However, no prospective study has evaluated the feasibility of early detection and treatment of allograft vasculopathy.

Methods. In 76 cardiac allograft recipients, 230 coronary angiographic and 376 scintigraphic studies were performed in a follow-up period of 8 years. Angiography was performed at 1 month and every year after transplantation, and thallium-201 scintigraphy at 1, 3, 6 and 12 months after transplantation and twice a year thereafter. Prospective follow-up of 76 patients showed that 18 developed either angiographic or scintigraphic evidence of coronary vasculopathy. All episodes were treated with 3-day methylprednisolone pulse and antithymocyte globulin.

Results. Twenty-two episodes of vasculopathy were diagnosed and treated in these 18 patients. Of these 22 episodes, two were detected only by angiography, seven by both angiography and scintigraphy, four by scintigraphy and histologic evidence of vasculitis and nine episodes only by thallium-201 scintigraphy studies. Angiographic and/or scintigraphic resolution was observed in 15 of the 22 episodes (68%) with augmented immunosuppression. The likelihood of regression was higher when treatment was instituted within the first year of transplantation (92%) than after the first year (40%) (p = 0.033). Eighty percent of patients who responded to follow-up.

Conclusions. The present study suggests that early detection of allograft coronary vasculopathy is feasible with surveillance myocardial perfusion or coronary angiographic studies. When identified early after transplantation, immunosuppressive treatment may result in regression of coronary disease.

Abbreviations and Acronyms   ISHLT = International Society of Heart and Lung Transplantation

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