Occult and frequent transmission of atherosclerotic coronary disease with cardiac transplantation: Insights from intravascular ultrasound

Background: Transplant coronary artery disease is a major cause of morbidity and mortality after cardiac transplantation. However, limited data exist regarding the potential contribution of coronary atherosclerosis in the donor heart to cardiac-allograft vasculopathy. Methods and Results: We performed quantitative coronary angiography and intravascular ultrasound imaging in 50 of 62 consecutive heart-transplant recipients (40 men, 10 women, mean age, 53±9 years) 4.6±2.6 weeks after transplantation. The donor population consisted of 30 men and 20 women (mean age, 32 ± 12 years). Ultrasound imaging visualized all three coronary arteries in 22 patients, two coronary arteries in 23, and one coronary artery in 5. Ultrasound imaging detected coronary atherosclerosis (intimal thickness ≥0.5 mm) in 28 patients (56%). However, the angiography was abnormal in only 13 patients (26%). The sensitivity and specificity of coronary angiography were 43% and 95%, respectively. With ultrasound, the average atherosclerotic plaque thickness was 1.3±0.6 mm and the cross-sectional area narrowing was 34±16%. Atherosclerotic involvement frequently was focal (85%), eccentric (mean eccentricity index, 87±8), and near arterial bifurcations. Donors of the transplant recipients with coronary atherosclerosis were older than those without atherosclerosis (37± 12 versus 25±10 years, P=.011). Maximal intimal thickness correlated with donor age (r=.54, P=.0001). Multivariate analysis demonstrated that donor age (P=.0001), male sex of donor (P=.0006), and recipient age (P=.03) were independent predictors of atherosclerosis. Conclusions: Coronary atherosclerosis is frequently but inadvertently transmitted by means of cardiac transplantation from the donor to the recipient. Long-term outcomes of donor-transmitted coronary artery disease will require further evaluation.