Cardiac Allograft Vasculopathy: What We Know in 2016

Cardiac allograft vasculopathy (CAV) is an immune and nonimmune-mediated process in which heart transplantation patients develop neointimal proliferative hyperplasia of the coronary arteries, typically starting distally and resulting in diffuse luminal narrowing. Risk factors include traditional coronary risk factors often resulting from side effects of immunosuppressive drugs, infection by cytomegalovirus and rejection, particularly antibody-mediated. Despite the advent of effective immunosuppression, CAV remains the primary cause of long-term mortality for heart transplant recipients. Patients undergo routine protocol surveillance for CAV after transplant, and various noninvasive and invasive diagnostic approaches can be employed in suspected CAV. Therapy is aimed primarily at prevention, given the incurable nature of CAV. The mainstay preventive therapies include statins and anti-proliferative immunosuppressive agents. In patients who develop CAV, treatment includes percutaneous coronary intervention and even retransplantation as CAV can result in irreversible systolic dysfunction and/or restrictive cardiomyopathy. This critical review aims to summarize our current knowledge of risk factors, diagnostic strategies, and therapy for CAV in heart transplant patients.