Improved Detection of Cardiac Allograft Vasculopathy: A Multi-Institutional Analysis of Functional Parameters in Pediatric Heart Transplant Recipients

J Am Coll Cardiol. 2015 Aug 4;66(5):547-57. doi: 10.1016/j.jacc.2015.05.063.


Background: Recent guidelines recommend assessment of systolic function and filling pressures to augment angiographic grading of cardiac allograft vasculopathy (CAV); however, no data exist on the utility of these guidelines.

Objectives: The aims of this study were to evaluate whether the assessment of systolic and diastolic graft function, in addition to angiography, improves recognition of patients at high risk of graft loss and to assess the ability of adult filling-pressure thresholds to discriminate graft dysfunction in pediatric patients.

Methods: This study reviewed Pediatric Heart Transplant Study data from 1993 to 2009. Graft dysfunction was defined as significant systolic dysfunction (ejection fraction [EF] <45%) or the presence of restrictive hemodynamic features. Additional pediatric hemodynamic cutpoints of right atrial pressure (RAP) >12 mm Hg or pulmonary capillary wedge pressure (PCWP) >15 mm Hg were analyzed.

Results: In the study, 8,122 angiograms were performed in 3,120 patients, and 70% of patients had at least 1 angiogram. Angiographic incidence of CAV was 5%, 15%, and 28% at 2, 5, and 10 years, respectively, and most disease was mild. The presence of graft dysfunction identified patients at greater risk for graft loss even in children with mild angiographic vasculopathy (p < 0.0001). An RAP >12 mm Hg or a PCWP >15 mm Hg was sufficient to detect patients at high risk of graft loss even with mild angiographic disease.

Conclusions: Patients with only mild angiographic CAV have significantly better outcomes than do patients with moderate or severe disease. The presence of an EF <45%, an RAP >12 mm Hg, or a PCWP >15 mm Hg identifies children at increased risk of graft loss even in the presence of only mild angiographic vasculopathy.

Keywords: chronic rejection; coronary artery; graft loss; heart transplant; hemodynamics; vasculopathy.

Publication types

  • Multicenter Study

MeSH terms

  • Adolescent
  • Allografts* / blood supply
  • Allografts* / physiopathology
  • Atrial Function, Right*
  • Child
  • Child, Preschool
  • Coronary Angiography / methods
  • Coronary Angiography / statistics & numerical data
  • Coronary Artery Disease* / diagnosis
  • Coronary Artery Disease* / etiology
  • Coronary Artery Disease* / physiopathology
  • Coronary Vessels* / diagnostic imaging
  • Coronary Vessels* / physiopathology
  • Female
  • Graft Rejection* / diagnosis
  • Graft Rejection* / etiology
  • Graft Rejection* / prevention & control
  • Heart Transplantation / adverse effects*
  • Heart Transplantation / methods
  • Heart Transplantation / statistics & numerical data
  • Hemodynamics
  • Humans
  • Infant
  • Kaplan-Meier Estimate
  • Male
  • Pulmonary Wedge Pressure*
  • Retrospective Studies
  • Risk Assessment
  • Severity of Illness Index
  • United Kingdom
  • United States
  • Vascular Patency