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Graft Coronary Artery Disease

Accelerated graft coronary artery disease (CAD) is a severe limitation of both adult and pediatric heart transplant recipients. Selective coronary angiography most likely underestimates the true incidence, but it is probably present in 20-40% of patients at 3-4 years posttransplant.23 Proposed etiologies include repeated cellular rejection episodes, hyperlipidemia, cytomegalovirus infection, and vascular rejection. Autopsies show a classic lesion of concentric intimal proliferation with an intact internal elastic lamina. The lesion is different than naturally occurring atherosclerosis. Surveillance is with coronary angiography and the recently introduced intraluminal ultrasound (IVUS).15 Our center has also used Dobutamine stress echocardiography as a screening tool for significant graft CAD.16 There is some evidence that captopril (an ACE inhibitor) may help prevent graft CAD.24 For patients with graft failure secondary to severe graft CAD, retransplantation may become necessary. We have retransplanted three patients for graft CAD.

Posttransplant Lymphoproliferative Disease (PTLD)

Chronic immunosuppression may lead to the development of malignancy following heart transplantation. At Children's Memorial Hospital 10 patients have developed PTLD, with successful treatment in seven.25 In some cases this is related to infection with Epstein-Barr virus. 26 PTLD presents with fever, malaise, leukopenia, and adenopathy. Early diagnosis with biopsy is important to determine whether the diagnosis is polyclonal or monoclonal, and to rule out infection. Most patients will respond to a reduction of immunosuppressive therapy, administration of acyclovir, or chemotherapy.

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