Vascular Disease of the Transplanted Heart: Physiopathology and Therapeutic Options

Abstract This chapter emphasizes the improvement in results of heart transplantation within decades and the attempts to improve long-term survival of graft vascular disease. The analysis of cellular and antibody mediated rejection, incidence of graft vascular disease, and characterization of coronary artery lesions in terms of pathology and distribution along the vessels are presented. A detailed description of immunological and nonimmunological factors that cause the initial lesion of the endothelium and the response of coronary wall is set out as well. Clinical presentation, noninvasive diagnostic approaches, coronary angiography, and coronary ultrasound evaluations are discussed. Lifestyle measures and drug therapy in prevention of this complication have limited efficacy. Furthermore angioplasty with stents or surgical revascularization can be indicated in select patients. In established disease immunosuppression with mTOR inhibitors decrease progression of coronary disease. Lastly, the use of a lipid nanoparticle with bound antiproliferative drugs (paclitaxel and methotrexate) in prevention of graft vascular disease is discussed; an important reduction of coronary lesions in transplanted hearts in rabbits with virtually no toxic effects was noted. Such findings open a promising perspective for future clinical applications.