Detection of early cardiac allograft vasculopathy in a high-risk transplant patient using optical coherence tomography

    Authors

    Keywords

    optical coherence tomography, cardiac allograft vasculopathy, positive-cross match

    DOI

    https://doi.org/10.15836/ccar2020.57

    Full Text

    Introduction : Cardiac allograft vasculopathy (CAV) is a common cause of late graft failure and mortality in heart transplant recipients. Concentric intimal proliferation that reflects immune-mediated vascular damage in the early post-transplant years is difficult to recognize by conventional coronary angiography. Optical coherence tomography (OCT) is a high-resolution intravascular imaging technique that has the potential to identify subtle early vessel wall changes and shape the therapeutic approach that may improve patients’ outcomes. ( 1 ) Case report : 68-year-old male patient underwent heart transplantation with positive lymphocyte crossmatch and Luminex that detected anti-HLA class I (A1, A25, B8, B57) donor-specific antibodies with MFI up to 2500. The patient was treated with steroid, antilymphocyte (rATG) induction, tacrolimus, and mycophenolate mofetil, in combination with IVIG and plasmapheresis. Graft function was preserved, biopsies showed no or mild cellular-mediated rejection (1R) with no signs of antibody-mediated rejection (AMR) with negativization of anti-A1 and -A25 antibodies. However, control biopsy after 6 months became positive for AMR. The patient was treated with steroid pulse, IVIG, plasmapheresis, and rituximab. The following biopsies were negative for AMR and the patient remained with preserved graft function. One year after transplantation we performed control coronary angiography with OCT. While coronary angiography was interpreted as normal, control OCT showed significant diffuse intimal thickening with maximal intimal thickness up to 920 µm and intima/media cross-sectional media of ≥1 ( Figure 1 ). This finding prompted a change in therapy with the maximization of statin dose and introduction of everolimus in the maintenance immunosuppressive regimen. Control OCT cross-sectional frame of a left anterior descending artery 12 months after heart transplantation. OCT = optical coherence tomography; I/M CSA = intima/media cross-sectional area. Conclusion : This case report indicates the limitation of conventional coronary angiography in the early detection of transplant vasculopathy. OCT is able to establish the diagnosis and trigger specific therapeutic interventions like the introduction of everolimus before vascular changes become visible on conventional coronary angiography and resistant to treatment. Unfortunately, we still lack clearly defined OCT criteria for both diagnosis and treatment, but the progress in this field of transplant cardiology is promising.

    Cardiologia Croatica
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    Detection of early cardiac allograft vasculopathy in a high-risk transplant patient using optical coherence tomography

    Extended Abstract
    Issue3-4
    Published
    Pages57
    PDF via DOIhttps://doi.org/10.15836/ccar2020.57
    optical coherence tomography
    cardiac allograft vasculopathy
    positive-cross match

    Authors

    Boško Skorić*ORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Joško BulumORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Hrvoje JurinORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Kristina Marić BešićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Maja ČikešORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Ivo PlanincORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Mia DubravčićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Dubravka ŠipušORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Renata ŽunecORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Marija Burek KamenarićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Davor MiličićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia

    Full Text

    Introduction : Cardiac allograft vasculopathy (CAV) is a common cause of late graft failure and mortality in heart transplant recipients. Concentric intimal proliferation that reflects immune-mediated vascular damage in the early post-transplant years is difficult to recognize by conventional coronary angiography. Optical coherence tomography (OCT) is a high-resolution intravascular imaging technique that has the potential to identify subtle early vessel wall changes and shape the therapeutic approach that may improve patients’ outcomes. ( 1 ) Case report : 68-year-old male patient underwent heart transplantation with positive lymphocyte crossmatch and Luminex that detected anti-HLA class I (A1, A25, B8, B57) donor-specific antibodies with MFI up to 2500. The patient was treated with steroid, antilymphocyte (rATG) induction, tacrolimus, and mycophenolate mofetil, in combination with IVIG and plasmapheresis. Graft function was preserved, biopsies showed no or mild cellular-mediated rejection (1R) with no signs of antibody-mediated rejection (AMR) with negativization of anti-A1 and -A25 antibodies. However, control biopsy after 6 months became positive for AMR. The patient was treated with steroid pulse, IVIG, plasmapheresis, and rituximab. The following biopsies were negative for AMR and the patient remained with preserved graft function. One year after transplantation we performed control coronary angiography with OCT. While coronary angiography was interpreted as normal, control OCT showed significant diffuse intimal thickening with maximal intimal thickness up to 920 µm and intima/media cross-sectional media of ≥1 ( Figure 1 ). This finding prompted a change in therapy with the maximization of statin dose and introduction of everolimus in the maintenance immunosuppressive regimen. Control OCT cross-sectional frame of a left anterior descending artery 12 months after heart transplantation. OCT = optical coherence tomography; I/M CSA = intima/media cross-sectional area. Conclusion : This case report indicates the limitation of conventional coronary angiography in the early detection of transplant vasculopathy. OCT is able to establish the diagnosis and trigger specific therapeutic interventions like the introduction of everolimus before vascular changes become visible on conventional coronary angiography and resistant to treatment. Unfortunately, we still lack clearly defined OCT criteria for both diagnosis and treatment, but the progress in this field of transplant cardiology is promising.