Changes in Coronary Anatomy and Physiology After Heart Transplantation

Cardiac allograft vasculopathy (CAV) is a progressive process involving the epicardial and microvascular coronary systems. The timing of the development of abnormalities in these 2 compartments and the correlation between changes in physiology and anatomy are undefined. The invasive evaluation of coronary artery anatomy and physiology with intravascular ultrasound, fractional flow reserve, coronary flow reserve, and the index of microcirculatory resistance (IMR) was performed in the left anterior descending coronary artery during 151 angiographic evaluations of asymptomatic heart transplant recipients from 0 to >5 years after heart transplantation (HT). There was no angiographic evidence of significant CAV, but during the first year after HT, fractional flow reserve decreased significantly (0.89 ± 0.06 vs 0.85 ± 0.07, p = 0.001), and percentage plaque volume derived by intravascular ultrasound increased significantly (15.6 ± 7.7% to 22.5 ± 12.3%, p = 0.0002), resulting in a significant inverse correlation between epicardial physiology and anatomy (r = −0.58, p <0.0001). The IMR was lower in these patients compared with those ≥2 years after HT (24.1 ± 14.3 vs 29.4 ± 18.8 units, p = 0.05), suggesting later spread of CAV to the microvasculature. As the IMR increased, fractional flow reserve increased (0.86 ± 0.06 to 0.90 ± 0.06, p = 0.0035 comparing recipients with IMRs ≤20 to those with IMRs ≥40), despite no difference in percentage plaque volume (21.0 ± 11.2% vs 20.5 ± 10.5%, p = NS). In conclusion, early after HT, anatomic and physiologic evidence of epicardial CAV was found. Later after HT, the physiologic effect of epicardial CAV may be less, because of increased microvascular dysfunction.