Coronary angiography after heart transplantation: Should perioperative study be the 'gold standard'?

The fact that allograft coronary arteriopathy is frequent and has a poor prognosis means early diagnosis is critical. Furthermore, because of important distinctions between native heart coronary artery disease and allograft arteriopathy, standard noninvasive diagnostic tests seem less sensitive and specific. Assuming that coronary angiography is the optimal method for detection and staging of allograft arteriopathy, one must establish the point at which an initial study should be performed and the incidence of abnormalities in donor hearts. Review of perioperative coronary angiograms in 75 consecutive patients undergoing heart transplantation (within 8 weeks) demonstrated that only six hearts had coronary artery abnormalities: two had focal coronary artery disease, one had an anomalous circumflex coronary artery, and three had nonobstructive calcification of the coronary arteries. To determine if serial quantitative angiography was helpful in detecting progression of coronary disease during a 12-month period, 28 patients underwent baseline and repeat quantification of mean luminal diameter of predetermined segments of the mid and distal portions of the left anterior descending artery. No patient had identifiable disease on the first angiogram, and 12 were studied in the first year of their transplants. During the interval, mean mid left anterior descending coronary diameter was 3.17 ± 0.6 mm on the first study and 3.06 ± 0.7 on the second study. Visual assessment of the angiograms, however, identified allograft arteriopathy when two studies were available for inspection in 7 of 28 patients despite no significant diameter reduction of identified coronary segments. These observations highlight the fact that visual inspection of coronary angiograms after heart transplantation is important for identification of abnormalities developing during a 12-month period and that a baseline study is essential. Because it is known that substantive intimal changes can be seen at autopsy within 3 months after surgery and that donors themselves are at risk of having coronary disease, baseline angiograms obtained 1 year after heart transplantation will be misleading. We believe that baseline coronary angiography should be performed as soon as possible (generally within 6 weeks) after heart transplantation.