Abstract Introduction Cardiac allograft vasculopathy (CAV) an immune-mediated process closely linked to rejection: endothelial injury in the coronary arteries of the transplanted heart, triggered by repeated episodes of rejection (cellular and antibody-mediated), ischemia-reperfusion injury, infections, and traditional cardiovascular risk factors. We present a case of progressive graft dysfunction in an elderly orthotropic heart transplant (OHT) recipient with advanced CAV requiring multiple coronary interventions, highlighting the complexity of late-stage disease management. Case Presentation A 78-year-old male with history of OHT six years ago underwent two-vessel coronary artery bypass grafting (CABG): saphenous vein graft (SVG) to left anterior descending (LAD) and obtuse marginal (OM) arteries. Within one year, he required a stent to the LAD graft and, shortly after, repeat percutaneous coronary intervention (PCI) for in-stent restenosis and primary PCI of OM. Four months later, he required primary PCI of right coronary artery (RCA) and repeat PCI for in-stent restenosis within the same week. After two years of stability, he again required PCI to RCA. Six months later, a repeat left heart catheterization demonstrated 100% stenosis of LAD graft and left circumflex artery requiring further interventions. Throughout these years, patient was noted to repeatedly have subtherapeutic serum immunosuppression levels, remained seropositive for cytomegalovirus, and developed new seropositivity for toxoplasma. He also had multiple episodes of obstructive uropathy. Eventually he was lost to follow up. Two years later, patient presented with anasarca attributed to decompensated heart failure with severe kidney injury. Echocardiogram demonstrated reduced biventricular systolic function with ejection fraction of 28% and severe pulmonary hypertension. A prior echocardiogram two years earlier had shown normal systolic function. Management focused on escalation of immunosuppression and aggressive IV diuresis, however he had poor response and required hemodialysis. The patient declined further invasive evaluation, and palliative care was consulted for goals-of-care discussion. Discussion CAV remains a major cause of late graft failure and limits long-term OHT survival. Management of established CAV remains limited, including optimization of immunosuppression, PCI, surgical revascularization, or re-transplantation, each with substantial limitations. Palliative PCI may be considered in limited disease cases, but its benefit in graft survival is unclear, while CABG is rarely performed due to diffuse and distal nature of CAV. Re-transplantation remains the only definitive therapy. In this patient, CABG provided only transient benefit. Subtherapeutic tacrolimus levels and loss of follow-up may have contributed. Cytomegalovirus infection and Toxoplasma gondii seropositivity have been associated with increased risk of developing CAV as well. This abstract is funded by: none
Khorsandi et al. (Fri,) studied this question.