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| ===Pharmacologic Management=== | | ===Pharmacologic Management=== |
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| ===Nonpharmacologic Interventions===
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| * Retransplantation
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| * [[Percutaneous coronary intervention]]s
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| * [[Coronary artery bypass grafting]] ([[CABG]])
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| * [[Transmyocardial revascularization]]
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| * [[LDL apheresis|Heparin induced/mediated extracorporeal LDL plasmapheresis]] (HELP)
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| ====Retransplantation====
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| * Retransplantation is the only definitive treatment for CAV. It is associated with satisfactory survival in patients with CAV.
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| * About 60% of the repeat transplantation procedures performed are due to graft failure secondary to CAV <ref name="pmid16686747">{{cite journal| author=Mehra MR| title=Contemporary concepts in prevention and treatment of cardiac allograft vasculopathy. | journal=Am J Transplant | year= 2006 | volume= 6 | issue= 6 | pages= 1248-56 | pmid=16686747 | doi=10.1111/j.1600-6143.2006.01314.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16686747 }} </ref>. It is a higher risk procedure and raises significant ethical concerns primarily because of scarcity of heart transplant donors <ref name="pmid12909465">{{cite journal| author=Radovancevic B, McGiffin DC, Kobashigawa JA, Cintron GB, Mullen GM, Pitts DE et al.| title=Retransplantation in 7,290 primary transplant patients: a 10-year multi-institutional study. | journal=J Heart Lung Transplant | year= 2003 | volume= 22 | issue= 8 | pages= 862-8 | pmid=12909465 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12909465 }} </ref>.
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| * Prognosis: One year survival has improved in recent years, but continues to be inferior compared to primary transplants (79% in re-transplant group compared to 85% in primary transplant group) <ref name="pmid10972218">{{cite journal| author=Srivastava R, Keck BM, Bennett LE, Hosenpud JD| title=The results of cardiac retransplantation: an analysis of the Joint International Society for Heart and Lung Transplantation/United Network for Organ Sharing Thoracic Registry. | journal=Transplantation | year= 2000 | volume= 70 | issue= 4 | pages= 606-12 | pmid=10972218 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10972218 }} </ref>.
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| ====Percutaneous Coronary Intervention====
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| * This procedure is limited only to a selected group of patients with focal disease in a single artery. Moreover, the number of patients who benefit are small.
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| * Incidence of re-stenosis is high, ranging from 20 to 60% as reported in various studies.
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| * [[Intracoronary stenting]] appears to have lower rate of re-stenosis as compared to [[coronary angioplasty]] alone.
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| * Concomitant use of high dose immunosuppressive therapy with [[azathioprine]] and [[mycophenolate]] have shown to significantly reduce the rate of re-stenosis <ref name="pmid15172400">{{cite journal| author=Benza RL, Zoghbi GJ, Tallaj J, Brown R, Kirklin JK, Hubbard M et al.| title=Palliation of allograft vasculopathy with transluminal angioplasty: a decade of experience. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 11 | pages= 1973-81 | pmid=15172400 | doi=10.1016/j.jacc.2004.02.045 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15172400 }} </ref>.
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| ====Coronary Artery Bypass Grafting====
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| * Associated with a high perioperative mortality especially in those with distal disease.
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| * In a retrospective analysis of 12 patients with CAV who underwent CABG, 4 died perioperatively, while only 7 were alive at the end of 9 months post-surgery <ref name="pmid7797740">{{cite journal| author=Halle AA, DiSciascio G, Massin EK, Wilson RF, Johnson MR, Sullivan HJ et al.| title=Coronary angioplasty, atherectomy and bypass surgery in cardiac transplant recipients. | journal=J Am Coll Cardiol | year= 1995 | volume= 26 | issue= 1 | pages= 120-8 | pmid=7797740 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7797740 }} </ref>.
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| ====Transmyocardial Revascularization====
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| * Also known as [[Transmyocardial revascularization|transmyocardial laser revascularization]] (TMLR), is a procedure involving creation of transmural channels in the myocardium to enhance blood supply.
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| * This procedure has been studied in multiple clinical trials in patients with refractory angina and those who are not considered as surgical candidates.
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| * Mehra and colleagues <ref name="pmid9230169">{{cite journal| author=Malik FS, Mehra MR, Ventura HO, Smart FW, Stapleton DD, Ochsner JL| title=Management of cardiac allograft vasculopathy by transmyocardial laser revascularization. | journal=Am J Cardiol | year= 1997 | volume= 80 | issue= 2 | pages= 224-5 | pmid=9230169 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9230169 }} </ref> first studied the effects of TMLR in patients with diffuse CAV. They reported significant improvement in symptoms and anginal class at 4 and 8 week follow up. However, at 24 month follow up, the procedure showed neither consistent symptomatic improvement nor any change in course of the progression of CAV <ref name="pmid10967275">{{cite journal| author=Mehra MR, Uber PA, Prasad AK, Park MH, Scott RL, McFadden PM et al.| title=Long-term outcome of cardiac allograft vasculopathy treated by transmyocardial laser revascularization: early rewards, late losses. | journal=J Heart Lung Transplant | year= 2000 | volume= 19 | issue= 8 | pages= 801-4 | pmid=10967275 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10967275 }} </ref>.
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| ====Heparin Induced/Mediated Extracorporeal LDL Plasmapheresis====
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| * Also known as LDL apheresis.
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| * Leads to significant reductions in [[LDL]], [[lipoprotein(a)]] levels and [[fibrinogen]].
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| * No effect on [[HDL]] levels.
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| * In a prospective study by Park et al., patients treated with LDL apheresis had a statistically significant increase in intraluminal diameter between 1 year and 2.5 years of follow up. However, long term trials are required to draw firm conclusions.
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| ==References== | | ==References== |