Mullins P A, Chauhan A, Sharples L, Cary N R, Large S R, Wallwork J, Schofield P M
Transplant Unit, Papworth Hospital, Huntingdon, Cambridge.
Br Heart J. 1992 Sep;68(3):266-71. doi: 10.1136/hrt.68.9.266.
Coronary occlusive disease is the major long-term complication after cardiac transplantation. The relation between minor angiographic abnormalities and myocardial perfusion has not been previously assessed in a large number of cardiac transplant patients.
Prospective study. Coronary flow reserve was measured with an intracoronary Doppler flow probe in the proximal left anterior descending coronary artery in each patient. A dose of intracoronary papaverine producing maximal vasodilation was then administered.
A regional cardiothoracic centre and a supraregional transplant unit.
Seven patients with chest pain but normal coronary anatomy (controls), and 61 cardiac transplant patients between three months and 10 years after operation (median 4.5 years). Twenty one cardiac transplant patients had angiographic evidence of minor coronary occlusive disease (mean (SD) percentage stenosis diameter 23% (6%)) in a primary or secondary coronary vessel (group 1), with 12 of these in the left anterior descending coronary artery (stenosis diameter (mean (SD) 24% (8%)). The remaining 40 transplant patients had normal coronary angiograms (group 2).
Coronary flow reserve was defined as the ratio of the peak flow velocity after papaverine to the resting flow velocity.
Group 1 patients had a noticeably impaired coronary flow reserve (2.6 (1.1)) compared with control patients (3.9 (0.4), p = 0.05) and, after adjusting for year after operation, compared with group 2 patients (3.8 (1.0), p < 0.001). No other variables were associated with a reduction in coronary flow reserve. Mean resting flow velocity was similar in all three groups (controls, 7.4 (4.6) cm/s; group 1, 7.5 (5.9) cm/s; and group 2, 7.3 (3.9) cm/s). Mean peak flow velocity response to papaverine was reduced in group 1 patients (18.1 (13.5) cm/s) relative to group 2 patients (27.5 (15.4) cm/s, p = 0.05) but not controls (28.4 (15.1) cm/s, p = 0.1).
Coronary flow reserve and the peak flow response to the coronary vascular smooth muscle relaxant papaverine are impaired in cardiac transplant patients with minor coronary occlusive disease. This disturbance of cardiac microvascular function may contribute to the late morbidity and mortality seen in cardiac transplant patients with coronary occlusive disease.
冠状动脉闭塞性疾病是心脏移植后的主要长期并发症。此前尚未在大量心脏移植患者中评估轻微血管造影异常与心肌灌注之间的关系。
前瞻性研究。使用冠状动脉内多普勒血流探头测量每位患者左前降支冠状动脉近端的冠状动脉血流储备。然后给予一剂能产生最大血管扩张作用的冠状动脉内罂粟碱。
一个地区心胸中心和一个超地区移植单位。
7名胸痛但冠状动脉解剖结构正常的患者（对照组），以及61名术后3个月至10年（中位时间4.5年）的心脏移植患者。21名心脏移植患者在主要或次要冠状动脉血管中有轻微冠状动脉闭塞性疾病的血管造影证据（平均（标准差）狭窄直径百分比为23%（6%））（第1组），其中12例在左前降支冠状动脉（狭窄直径（平均（标准差）24%（8%））。其余40名移植患者冠状动脉造影正常（第2组）。
冠状动脉血流储备定义为罂粟碱给药后峰值流速与静息流速之比。
与对照组患者（3.9（0.4））相比，第1组患者的冠状动脉血流储备明显受损（2.6（1.1）），差异有统计学意义（p = 0.05）；在对术后年份进行校正后，与第2组患者（3.8（1.0））相比，差异有高度统计学意义（p < 0.001）。没有其他变量与冠状动脉血流储备降低相关。三组患者的平均静息流速相似（对照组，7.4（4.6）cm/s；第1组，7.5（5.9）cm/s；第2组，7.3（3.9）cm/s）。相对于第2组患者（27.5（15.4）cm/s，p = 0.05），第1组患者对罂粟碱的平均峰值流速反应降低，但与对照组（28.4（15.1）cm/s，p = 0.1）相比无差异。
患有轻微冠状动脉闭塞性疾病的心脏移植患者的冠状动脉血流储备以及对冠状动脉血管平滑肌松弛剂罂粟碱的峰值血流反应受损。这种心脏微血管功能障碍可能导致患有冠状动脉闭塞性疾病的心脏移植患者出现晚期发病率和死亡率。
