Coronary artery bypass grafting after orthotopic heart transplantation.

OBJECTIVE: Graft coronary disease (GCD) remains the major determinant of long-term survival after heart transplantation. Therapeutic strategies for the prevention or retardation of GCD in the cardiac allograft are limited, and palliative surgical coronary revascularization has been attempted. The aim of this report was to retrospectively analyze our results of coronary artery bypass grafting after cardiac transplantation. This paper correlates the outcome of patients with the pathohistological and angiographic type of lesion in order to identify transplant recipients who may profit from surgical myocardial revascularization.
METHODS: Seven patients with a mean age of 55 years (range 45-61 years) underwent coronary artery bypass grafting as a result of GCD at a mean of 67 months (range 6-128 months) after cardiac transplantation. By the inclusion of the clinical history and the angiographic pattern of GCD lesions, the primary indications for surgical revascularization, operative results, pathohistological studies and follow-ups were examined.
RESULTS: Elective surgery was performed in two patients with proximal, severe triple vessel disease (Type A lesion) and in one patient in whom the primary reason for cardiac surgery was severe tricuspid regurgitation. This patient electively received a tricuspid valve replacement and concomitant single vessel bypass surgery for proximal GCD (Type A lesion). Emergency surgery was performed in four patients: preoperatively three patients post-infarction developed worsening congestive heart failure, which resulted in low cardiac output syndrome. One patient with combined Types A and B/C lesions required emergency surgery for dissection of the right coronary artery (RCA) after an angioplasty procedure. Angiographically all these patients showed diffuse, distal arteriopathy (combined Type B/C lesions). The electively operated patients (n = 3) and the patient with dissection of the RCA (n = 1) had successful operations and survived beyond hospital discharge (overall survival for coronary artery bypass graft (CABG) in GCD patients 4 out of 7; 57%). All three patients with distal arteriopathy, who underwent emergency surgery, died in hospital from left ventricular failure (43%). The four patients discharged from hospital with a mean follow-up of 10 months (range 2-32 months) are all in good clinical condition.
CONCLUSIONS: Coronary artery bypass grafting can be successfully performed in a subgroup of cardiac transplant patients with Type A lesions. However, the state of diffusely diseased distal arteries (Type B/C lesions), which is prevalent in this group of patients, limits the use of bypass surgery.