Clinical research progress of cardiac allograft vasculopathy

doi:10.3877/cma.j.issn.1674-3903.2022.04.009

Abstract

Abstract:

As one of the main factors limiting the survival time of patients after heart transplantation, cardiac allograft vasculopathy (CAV) and its exact pathogenesis remains to be explored, which involves vascular endothelial damage and repair response caused by a variety of immune responses and the interaction of non-immune factors. Coronary angiography is the current gold standard for the diagnosis of CAV. Furthermore, transjugular endomyocardial biopsy and intravascular ultrasound are also used to assess CAV. The surgical treatment for CAV is fairly limited. Heart retransplantation is not recommended in clinical practice because of the shortage of donor organs and high risk of complications. Percutaneous coronary intervention and coronary artery bypass grafting can only be used as restricted palliative treatment. Therefore, drug intervention is the current focus for the treatment of CAV. The pathogenesis and drug treatment of CAV will still be the key research direction of heart transplantation for some time to come.

Key words: Cardiac allograft vasculopathy, Heart transplantation, Pathogenesis, Diagnosis, Immune induction, Immunosuppression

Chang Liu, Daxing Liu. Clinical research progress of cardiac allograft vasculopathy[J]. Chinese Journal of Transplantation(Electronic Edition), 2022, 16(04): 241-248.

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分级	病变程度	冠状动脉造影术诊断标准
0级	无意义	无明显狭窄
1级	轻度	左主干狭窄<50%或主要血管狭窄<70%或分支狭窄<70%
2级	中度	左主干狭窄<50%，单支主要血管狭窄≥70%或单一分支出现2处区域狭窄≥70%
3级	重度	左主干狭窄≥50%或≥2支主要血管狭窄≥70%或单一分支出现3处区域狭窄或CAV 1级、2级受者出现移植物功能失调(左心室射血分数≤45%)或出现明显的心功能受限表现

分级	病变程度	冠状动脉造影术诊断标准
0级	无意义	无明显狭窄
1级	轻度	左主干狭窄<50%或主要血管狭窄<70%或分支狭窄<70%
2级	中度	左主干狭窄<50%，单支主要血管狭窄≥70%或单一分支出现2处区域狭窄≥70%
3级	重度	左主干狭窄≥50%或≥2支主要血管狭窄≥70%或单一分支出现3处区域狭窄或CAV 1级、2级受者出现移植物功能失调(左心室射血分数≤45%)或出现明显的心功能受限表现

检查方式	优势	局限性
冠状动脉造影	详细了解整个冠状动脉的受累情况，也便于对心脏移植受者的纵向随访	有创检查，易低估受者病情进展
经颈静脉心内膜心肌活检术	可对部分受者的移植后微血管病变进行早期诊断	有创检查，无临床症状的受者阳性检出率低
血管内超声	可测量最大内膜厚度、冠状动脉血流储备等指标	有创性检查，目前无法做到对整个冠状动脉系统进行测量，且该操作对受者有较高风险
冠状动脉CT血管成像	无创检查，能准确判断冠状动脉狭窄和钙化受累情况，具备临床可参考的特异度和敏感度	成像分辨率受呼吸和心跳频率影响，碘造影剂具有肾毒性
光学相干层析成像	对心脏移植后受者血管壁厚度的微小变化敏感，可对CAV 0级受者进行较早期诊断	该技术在临床的运用目前仍在研究
心脏磁共振显像	无创检查，不使用具有肾毒性的造影剂，同时还能评估受者心肌前后负荷、灌注情况及心室舒缩功能	特异度和阳性预测值较低

检查方式	优势	局限性
冠状动脉造影	详细了解整个冠状动脉的受累情况，也便于对心脏移植受者的纵向随访	有创检查，易低估受者病情进展
经颈静脉心内膜心肌活检术	可对部分受者的移植后微血管病变进行早期诊断	有创检查，无临床症状的受者阳性检出率低
血管内超声	可测量最大内膜厚度、冠状动脉血流储备等指标	有创性检查，目前无法做到对整个冠状动脉系统进行测量，且该操作对受者有较高风险
冠状动脉CT血管成像	无创检查，能准确判断冠状动脉狭窄和钙化受累情况，具备临床可参考的特异度和敏感度	成像分辨率受呼吸和心跳频率影响，碘造影剂具有肾毒性
光学相干层析成像	对心脏移植后受者血管壁厚度的微小变化敏感，可对CAV 0级受者进行较早期诊断	该技术在临床的运用目前仍在研究
心脏磁共振显像	无创检查，不使用具有肾毒性的造影剂，同时还能评估受者心肌前后负荷、灌注情况及心室舒缩功能	特异度和阳性预测值较低

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