Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ KEY FEATURES +++ ESSENTIALS OF DIAGNOSIS ++ Diffuse, concentric coronary artery narrowing on angiography due to a panarteritis Maximal intimal thickness on intravascular ultrasound > 0.5 mm Angina pectoris rare due to denervation of the allograft +++ GENERAL CONSIDERATIONS ++ Incidence is 8% at 1 year, 30% at 5 years, and 50% at 10 years It is the main cause of late posttransplantation deaths and is the main factor limiting long-term survival Noninvasive tests are less useful in assessing this disease Recipient characteristics (eg, hypertension, hyperlipidemia, insulin resistance, and cytomegalovirus infection) and donor characteristics (eg, preexisting coronary disease, donor ischemic time) may play a role Thought to be a form of chronic rejection, but the pathophysiology is complex When heart failure is present, it is more likely due to a restrictive myocardial physiology rather than left ventricular systolic dysfunction +++ CLINICAL PRESENTATION +++ SYMPTOMS AND SIGNS ++ Dyspnea Sudden death Ventricular arrhythmia Angina is rare despite advanced graft vasculopathy +++ PHYSICAL EXAM FINDINGS ++ Features of heart failure may be present +++ DIFFERENTIAL DIAGNOSIS ++ Acute rejection Cytomegalovirus infection +++ DIAGNOSTIC EVALUATION +++ LABORATORY TESTS ++ No specific lab tests have proven useful Cardiac biomarker elevation if there is acute myocardial infarction (MI) +++ ELECTROCARDIOGRAPHY ++ ECG may indicate acute MI Ventricular arrhythmias may signify allograft vasculopathy +++ IMAGING STUDIES ++ Echocardiography may show mitral valve E/A wave amplitude ratio > 2 in restrictive cardiomyopathy Doppler echocardiography may show early mitral valve inflow velocity deceleration time < 150 ms in restrictive cardiomyopathy Dobutamine echocardiography (DSE) may offer reasonable sensitivity and specificity DSE may also provide prognostic value +++ diagnostic PROCEDURES ++ Right heart catheterization evidence of restrictive cardiomyopathy: – Right atrial pressure > 12 mm Hg – Pulmonary capillary wedge pressure > 25 mm Hg – Cardiac index < 2 L/min/m2 Coronary angiography: – The disease is diffuse and concentric and easy to miss on angiogram – Diameter comparison with prior angiogram is critical in recognizing the condition – Collateral vessel formation is uncommon Intravascular ultrasound is a promising tool for early recognition of allograft vasculopathy +++ TREATMENT +++ CARDIOLOGY REFERRAL ++ All patients are usually followed by a transplantation cardiologist +++ HOSPITALIZATION CRITERIA ++ Heart failure Acute MI Symptomatic arrhythmia +++ MEDICATIONS ++ Pravastatin useful for prevention regardless of blood lipid levels Calcium blockers plus angiotensin-converting enzyme inhibitors useful for hypertension Vitamins C and E have shown efficacy for prevention Everolimus plus cyclosporine may be better than azathioprine plus cyclosporine ++... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.