Long Term Survival and Graft Related Outcomes After Percutaneous Coronary Intervention for Cardiac Allograft Vasculopathy in Contemporary Australian Heart Transplant Recipients

Aim: Cardiac allograft vasculopathy (CAV) remains a leading cause of late graft dysfunction and mortality after heart transplantation (HTx). Characterised by diffuse concentric intimal hyperplasia and microvascular involvement, CAV differs from conventional atherosclerotic coronary disease and often progresses despite optimal medical therapy. Although percutaneous coronary intervention (PCI) is frequently performed for focal CAV, contemporary long term graft and patient outcomes in Australian transplant recipients are not well characterised. We evaluated survival and major transplant related adverse outcomes following PCI for CAV in a contemporary single centre HTx cohort.
Method: We conducted a retrospective study of adult HTx recipients undergoing PCI for angiographically significant CAV between 2009 and 2025 at a tertiary transplant centre. Primary outcomes were overall survival, strict major adverse cardiovascular events (MACE) defined as death, myocardial infarction or stroke, and widened MACE defined as strict MACE plus repeat revascularisation or re transplantation. Time to event outcomes were estimated using Kaplan Meier methods, and age adjusted Cox regression was used to identify predictors of mortality and widened MACE.
Results: Thirty five HTx recipients underwent PCI at a median of 11.3 years post-transplant (IQR 9.2 to 14.3), consistent with late stage CAV. Comorbidity burden was substantial: hypertension 66%, chronic kidney disease 51%, diabetes 49% and dyslipidaemia 91%. Most patients received calcineurin inhibitor therapy (71%), predominantly tacrolimus (49%), and a proliferation signal inhibitor (60%), most commonly everolimus (37%), in combination with prednisone (66%) and mycophenolate (66%). Indications for PCI were angina or inducible ischaemia on non-invasive stress testing (45.7%), surveillance detected disease (31.4%) and acute myocardial infarction (22.9%). There were no in hospital deaths, cardiogenic shock or definite stent thrombosis.
Over a median follow up of 7.3 years, overall mortality was 43% (15/35), with a median survival after PCI of 7.5 years. Strict and widened MACE occurred in 57% and 71% of recipients respectively, with five year strict and widened MACE free survival of 46.9% and 31.7%. Chronic kidney disease independently predicted mortality (HR 4.06, 95% CI 1.06 to 15.50), while prior myocardial infarction predicted widened MACE (HR 5.09, 95% CI 1.29 to 20.09).
Conclusion: In contemporary Australian HTx recipients, PCI for late CAV is associated with excellent short term procedural safety but substantial long term graft and patient attrition. These findings underscore that focal revascularisation does not halt the progressive nature of CAV and highlight the need for enhanced risk stratification and structured longitudinal surveillance to improve long term graft survival and patient outcomes.