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CLINICAL RESEARCH: HEART TRANSPLANTATION

The impact of mode of donor brain death on cardiac allograft vasculopathy

An intravascular ultrasound study

^* Ochsner Cardiomyopathy and Heart Transplantation Center, Ochsner Medical Institutions, New Orleans, Louisiana, USA

Manuscript received July 25, 2003; accepted August 13, 2003.

^* Reprint requests and correspondence: Dr. Mandeep R. Mehra, Cardiomyopathy and Heart Transplantation Center, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, Louisiana 70121, USA.
mmehra{at}ochsner.org

OBJECTIVES: We evaluated the association of mode of brain death with cardiac allograft vasculopathy.

BACKGROUND: Explosive brain death (EBD) is accompanied by a sudden increase in intracranial pressure, with recruitment of pro-inflammatory cytokines, as well as adhesion cell and co-stimulatory molecules. Whether these early events influence the later development of cardiac allograft vasculopathy following heart transplantation remains unknown.

METHODS: An inception cohort of 61 consecutive heart transplant recipients between 1993 and 1995 who underwent intravascular ultrasound examination of the coronary arteries were evaluated. Based on the mode of donor brain death, this cohort was divided into either an EBD group (n = 27) or non-EBD (n = 34), and the development of intimal thickness and cardiac events (sudden cardiac death, myocardial infarction, and need for coronary revascularization via percutaneous techniques or surgical bypass) was assessed.

RESULTS: Despite similar posttransplant survival and distribution of nonimmunological and immunological variables, heart transplant recipients with EBD demonstrated greater intimal thickening (0.59 ± 0.1 vs. 0.32 ± 0.2 mm; p = 0.02) and higher cardiac events (37% vs. 12%; p = 0.01) when compared to those with non-EBD donors. Hearts from donors with EBD had lower survival (63 ± 19 vs. 72 ± 17 months) than with non-EBD donors (p = 0.04).

CONCLUSIONS: Explosive brain death is a significant determinant for the late development of cardiac allograft vasculopathy and influences long-term allograft survival. Thus, strategies focusing on limitation of vascular allograft injury in the pre-engraftment phase of cardiac transplantation are warranted.

Abbreviations and Acronyms   CAD = coronary artery disease   CMV = cytomegalovirus   EBD = explosive brain death   HLA = human leukocyte antigen   ISHLT = International Society for Heart and Lung Transplantation   JNC = Joint National Commission

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