Risk-Stratified Cardiovascular Screening Including Angiographic and Procedural Outcomes of Percutaneous Coronary Interventions in Renal Transplant Candidates

Background. Benefits of cardiac screening in kidney transplant candidates (KTC) will be dependent on the availability of effective interventions. We retrospectively evaluated characteristics and outcome of percutaneous coronary interventions (PCI) in KTC selected for revascularization by a cardiac screening approach. Methods. In 267 patients evaluated 2003 to 2006, screening tests performed were reviewed and PCI characteristics correlated with major adverse cardiovascular events (MACE) during a follow-up of 55 months. Results. Stress tests in 154 patients showed ischemia in 28 patients (89% high risk). Of 58 patients with coronary angiography, 38 had significant stenoses and 18 cardiac interventions (6.7% of all). 29 coronary lesions in 17/18 patients were treated by PCI. Angiographic success rate was 93.1%, but procedural success rate was only 86.2%. Long lesions (P=0.029) and diffuse disease (P=0.043) were associated with MACE. In high risk patients, cardiac screening did not improve outcome as 21.7% of patients with versus 15.5% of patients without properly performed cardiac screening had MACE (P=0.319). Conclusion. The moderate procedural success of PCI and poor outcome in long and diffuse coronary lesions underscore the need to define appropriate revascularization strategies in KTC, which will be a prerequisite for cardiac screening to improve outcome in these high-risk patients

Intravaskuläre Ultraschalluntersuchung bei Diagnostik und interventioneller Therapie von Herzkranzgefäßerkrankungen am Beispiel der Transplantatvaskulopathie

Es wurde die Bedeutung der intravaskulären Ultraschalluntersuchung (IVUS) bei Diagnostik (1) und interventioneller Therapie (2) der koronaren Herzerkrankung am Beispiel der Transplantatvaskulopathie (TVP) untersucht. 1. Bei 321 Patienten post-HTx-Patienten ohne relevante Stenosen im Koronarangiogramm wurde eine dreidimensionale Rekonstruktion des Ramus interventricularis anterior (LAD) und des linkskoronaren Hauptstammes aus den mittles manueller Katheterrückzugstechnik aquirierten IVUS-Bildern durchgeführt und die intrakoronare Plaqueverteilung und die mittlere Plaquelast der einzelnen Koronarsegmente analysiert. Bei 296 Patienten (92%) fanden angiographisch nicht sichtbare frühe Plaquebildung. 48% dieser Patienten zeigten ein fokal,polyfokale, 52% ein diffuses Plaqueverteilungsmuster. Unabhängige Prädiktoren für das Auftreten einer diffusen TVP waren männliches Geschlecht des Empfängers, das Zeitintervall zwischen HTx und IVUS-Untersuchung (Transplantationszeit) und das Spenderalter. In beiden morphologischen Untergruppen war ein häufigere und stärkere Plaquebildung in den proximalen Koronarsegmenten nachweisbar. Ein distaler Gefäßbefall war bei diffuser Plaquebildung signifikant häufiger und zeigte eine steigende Inzidenz mit zunehmender Transplantationszeit. Somit stellt das longitudinale Plaqueverteilungsmuster und der distale Gefäßbefall einen zusätzlichen morphologischen Marker für den Schweregrad einer beginnenden Transplantatvaskulopathie dar. 2. Bei 36 post-HTx Patienten wurden 62 Stenosen prospektiv mit einer IVUS-gesteuerten, gefäßgrößen-adaptierten Stentimplantation erfolgreich versorgt. Die Stentgröße wurde dem Mittelwert aus Lumen- und Gefäßdurchmessers im proximalen Referenzsegment angepaßt. Nach Vordilatation fand sich ein Lumengewinn von 1.26± 0.16 auf 1.95 ± 0.27mm, nach abschließender Stentimplantation auf 2.94 ± 0.37mm. Nach 6 Monaten betrug die binäre In-Stent-Restenosierungsrate 21.8%, eine Re-PTCA wurde bei 10.9 % durchgeführt.The role of intravascular ultrasound imaging in diagnosis of coronary disease (1) and guiding percutaneous coronary intervention (2) was evaluated in patients with transplant vasculopathy. 1. In 321 post-HTx-patients without angiographic evidence of coronary disease, three-dimensional intravascular ultrasound imaging of the left anterior descending coronary artery (LAD) and the left main coronary artery was performed. Intracoronary plaque distribution and plaque burden was evaluated for each coronary segment. In 296 patients (92%) angiographically silent plaque was detected by IVUS. 48% of these patients showed a focal,polyfocal and 52% a diffuse plaque distribution pattern. Independent predictors of diffuse plaque formation were male gender of the recipient, transplantation time and donor age. In both morphological subgroups of plaque distribution the incidence and magnitude of plaque formation was highest in the proximal LAD segment. Plaque formation in the distal LAD was more frequent in diffuse plaque formation and increased significantly with time after transplantation. Therefore longitudinal plaque distribution pattern and distal vessel involvment are useful additional morphological markers for staging of beginning transplant vasculopathy. 2. In 36 post-HTx-patients 62 coronary stenosis were successfully treated by vessel-size adapted stenting by use of intravascular ultrasound guidance. The stent size was adapted to the proximal reference segment´s mean of lumen/vessel diameter. After pre-dilatataion the minimal lumen diameter increased from 1.26± 0.16 to 1.95 ± 0.27mm and to 2.94 ± 0.37mm after final stent implantation. After 6 months, binary in-stent-restenosis rate was 21.8% and target vessel revascularization rate 10.9%, respectively

Medium-term results of heart transplantation using older donor organs

Background: Donor heart shortage has necessitated the expansion of the donor pool by the use of older hearts. In a 13-year period, 1,070 heart transplants were performed in 1,035 adults at the German Heart Institute Berlin. We divided the patients into 3 groups: Group I, donor age <35 years ( n = 524); Group II, donor age 35 to 50 years ( n = 379); Group III, donor age >50 years ( n = 167). We analyzed post-operative mortality (up to 30 days), cumulative survival rates, cardiac dependent morbidity, and changes in the left/right ventricular ejection fraction as well as freedom from cytomegalovirus infection and freedom from acute rejection episodes grade ≥ 2 (International Society for Heart and Lung Transplantation). We also calculated the rate of cardiac interventions per patient in the groups. Recipients in Group III were significantly older, compared with Groups I and II. The post-operative mortality was 16.8% in Group I, 29.8% in Group II, and 23.4% in Group III. The differences were significant ( p = 0.00001) between Group I and Group II. The long-term cumulative survival rates were significantly better in Group I when compared with Groups II and III ( p < 0.00001 , p = 0.014), but it did not differ between Groups II and III ( p = 0.18). However, cardiac morbidity in Groups I and II was significantly lower when compared with Group III ( p = 0.0009, p = 0.037). Mean left and right ventricular ejection fraction was >55% and did not significantly change in groups for up to 10 years. Freedom from cytomegalovirus infection was not significantly different between Groups II and III ( p = 0.09). Significantly fewer percutaneous transluminal coronary angioplasties were performed in Group I, but comparable numbers were carried out in Groups II and III ( p = 0.53). For retransplantation a similar situation occurred. We did not find significant differences in the mid-term follow-up between patients who received hearts from 35- to 50-year-old donors and from those who had received hearts from donors >50 years, despite increased cardiac morbidity in Group III. Close monitoring of the coronary situation after heart transplantation and expanded indications for revascularization in Group III makes heart transplantation with older hearts a suitable option to save the lives of patients in end-stage heart failure