Prevention of Cardiac Allograft Vasculopathy in Heart Transplantation

Heart transplantation is a well established therapy for end-stage heart failure. Long-term results are limited by malignancy and cardiac allograft vasculopathy. The causes for cardiac allograft vasculopathy and the predictors for its onset and progression are multifactorial and determined by both immunological and non-immunological risk factors. The detection of cardiac allograft vasculopathy is difficult owing to the denervation of the allograft and the diffuse disease progression, especially in medium-sized and smaller arteries, in a diffuse and concentric fashion. The treatment options are limited and often do not provide long-term success so that retransplantation remains the only solution in some cases. Therefore, the emphasis has to be placed on cardiac allograft vasculopathy prevention. A variety of strategies for endothelial protection exist, beginning with matching and virtual crossmatching prior to transplantation. Further approaches involve preservation solutions and additives as well as transportation modalities and the prevention of ischemic injury during reperfusion. After transplantation, the interplay of recipient nonimmune cardiovascular risk factors and the effects of cellular and antibody mediated rejection both injuring the allograft endothelium have to be considered, leading to an optimized medical prevention of cardiac allograft vasculopathy. Established medical approaches for cardiac allograft vasculopathy prevention involve statins, vasodilators, infection prophylaxis, proliferation signal inhibitors, mycophenolate mofetil, and endothelial protective agents. This review will look at the pathophysiology of cardiac allograft vasculopathy, its diagnosis, and current and future concepts for cardiac allograft vasculopathy prevention. (Trends in Transplant. 2010;4:58-67)