Update on cardiac allograft vasculopathy

Cardiac allograft vasculopathy remains one of the main causes of morbidity and mortality after heart transplantation, although its impact is becoming somewhat smaller as prophylactic measures are implemented. Consensus is needed on a working definition of the disease as detected by different diagnostic techniques. Advances in the understanding of the molecular and cellular mechanisms involved in the genesis and development of cardiac allograft vasculopathy will undoubtedly create ways for new diagnostic and therapeutic strategies. Currently available tools for anatomic and physiologic diagnosis of the disease have allowed a better understanding of the dynamic interaction between intimal growth “passenger” atherosclerotic plaques and vascular remodeling that integrates cardiac allograft vasculopathy. The emerging concept of vascular compartments may help to explain the time-related differences in anatomic and functional abnormalities found in each vascular segment at different stages of the disease. Successful prophylaxis of the early stages of the disease has been recently demonstrated with the use of newer immunosuppressive agents that will probably be included in future protocols. In patients with severe cardiac allograft vasculopathy and suitable anatomy, newly designed drug-eluting stents or brachytherapy must be tested in an attempt to overcome the known limitations of conventional revascularization strategies. Selected patients with end-stage disease could be candidates for retransplantation.