Nicolas Ramzi T, Kort Henry W, Balzer David T, Trinkaus Kathryn, Dent Catherine L, Hirsch Russel, Canter Charles E
Department of Pediatrics, Washington University, St. Louis, Missouri, USA.
J Heart Lung Transplant. 2006 Aug;25(8):921-7. doi: 10.1016/j.healun.2006.03.022. Epub 2006 Jul 11.
Transplant coronary arteriopathy (TCAD) limits graft survival after heart transplantation in adult and pediatric heart transplant recipients. Intravascular ultrasound (IVUS) provides a highly sensitive technique to detect TCAD. However, its use to determine factors associated with TCAD in pediatric recipients has been limited and its utility in surveillance for symptomatic TCAD in this population is uncertain.
One hundred fifty-eight IVUS studies from 66 patients (27 <1 year and 39 >1 year at time of transplant) were performed 12 to 144 months after transplantation within the routine surveillance for TCAD. Maximal intimal thickness (MIT) and intimal index (II) were measured, and the Stanford classification was utilized to grade overall severity of disease. Mixed repeated-measures linear regression models were used to investigate the main and interaction effects of age at transplant, age at time of study, time since transplant and rejection events.
Age at catheterization (p = 0.0002), transplantation at age >12 months (p = 0.014), increasing time after transplantation (p = 0.021) and the combination of late rejection and hemodynamic compromising rejection (p = 0.05) were significantly associated with increasing MIT. Age at catheterization (p = 0.0149), transplantation at age >12 months (p = 0.016), time from transplantation (p = 0.0076) and rejection with hemodynamic compromise (p = 0.01) were significantly associated with increased II. Nine patients developed evidence of severe (Stanford Class 4) TCAD by IVUS, but only 2 (22%) developed symptomatic TCAD, with a median follow-up of 44 months. Four of the 7 patients who developed symptomatic TCAD had no or minimal TCAD (Stanford Class 0 or 1) on a surveillance examination within 18 months of the onset of symptoms.
Increasing time after transplantation, recipient age and age at transplantation as well as rejection history, especially rejection with hemodynamic compromise, are associated with the development of TCAD as detected by IVUS in pediatric heart transplant recipients. Severe TCAD detected by IVUS does not often rapidly progress to symptomatic TCAD. Symptomatic TCAD may develop rapidly even in patients with little or no TCAD detected by IVUS.
移植冠状动脉病变（TCAD）限制了成人和儿童心脏移植受者心脏移植后的移植物存活。血管内超声（IVUS）是检测TCAD的一种高度敏感的技术。然而，其在确定儿科受者中与TCAD相关因素方面的应用有限，并且其在该人群中有症状TCAD监测中的效用尚不确定。
在对66例患者（移植时27例＜1岁，39例＞1岁）进行的158项IVUS研究中，于移植后12至144个月在TCAD的常规监测期间进行。测量最大内膜厚度（MIT）和内膜指数（II），并采用斯坦福分类法对疾病的总体严重程度进行分级。使用混合重复测量线性回归模型来研究移植时年龄、研究时年龄、移植后时间和排斥事件的主要和交互作用。
导管插入时的年龄（p = 0.0002）、12个月以上年龄移植（p = 0.014）、移植后时间增加（p = 0.021）以及晚期排斥和血流动力学损害性排斥的联合（p = 0.05）与MIT增加显著相关。导管插入时的年龄（p = 0.0149）、12个月以上年龄移植（p = 0.016）、移植后的时间（p = 0.0076）和血流动力学损害性排斥（p = 0.01）与II增加显著相关。通过IVUS，9例患者出现严重（斯坦福4级）TCAD的证据，但仅2例（22%）出现有症状的TCAD，中位随访时间为44个月。7例出现有症状TCAD的患者中，4例在症状出现后18个月内的监测检查中无或仅有轻微TCAD（斯坦福0级或1级）。
移植后时间增加、受者年龄和移植时年龄以及排斥史，尤其是血流动力学损害性排斥，与儿科心脏移植受者中IVUS检测到的TCAD的发生相关。IVUS检测到的严重TCAD并不常迅速进展为有症状的TCAD。即使在IVUS检测到很少或没有TCAD的患者中，有症状的TCAD也可能迅速发展。
