A Decade of Percutaneous Coronary Interventions in Cardiac Transplant Recipients: A Monocentric Study in 160 Patients Ernst Wellnhofer, MD, a Nicola E. Hiemann, MD, b Jürgen Hug, MD, a Stefan Dreysse, MD, a Christoph Knosalla, MD, PhD, b Kristof Graf, MD, a Rudolph Meyer, MD, PhD, b Hans B. Lehmkuhl, MD, b Roland Hetzer, MD, PhD, b and Eckart Fleck, MD a Background: Transplant vasculopathy is a long-term complication of cardiac transplantation. Percutaneous transluminal coronary angioplasty (PCI) is a method of choice for local revascularization that is also increasingly used in heart transplant patients. Methods: Between October 1989 and November 2006, 160 adult cardiac transplant recipients (19 women) with mean age at heart transplantation of 47  12 years underwent PCI in 502 coronary segments during 319 catheterizations (balloon only, 209; bare metal stents, 227, drug-eluting stents, 66). Concomitant medical therapy, procedural data, primary success, recurrence of stenosis, and cardiac events (cardiac death or repeat transplantation) were analyzed retrospectively. Multivariate Cox proportional hazards analysis was performed. Results: Stents reduced early and mid-term recurrence of stenosis but had no impact on graft survival. Drug-eluting stents did not improve the restenosis rate. Immunosuppression with mycophenolate mofetil and concomitant treatment with statins and clopidogrel were significantly associated with reduced recurrence of stenosis and prolonged graft survival. Low steroid dosage was associated with a positive impact on graft survival. Conclusions: Stenting in heart transplant patients has no impact on graft survival despite high primary success and deferred recurrence of stenosis. Early reduction of steroids, immunosuppression by mycophenolate mofetil, and concomitant treatment with statins are likely to reduce recurrent stenosis and to improve graft survival in heart transplant patients needing PCI. Long-term treatment with clopi- dogrel deserves further assessment. J Heart Lung Transplant 2008;27:17–25. Copyright © 2008 by the International Society for Heart and Lung Transplantation. Transplant vasculopathy remains a major cause of long- term morbidity and mortality among heart transplant (Htx) recipients. 1 Percutaneous transluminal coronary an- gioplasty (PCI) is a treatment of choice for focal stenoses in epicardial vessels in coronary artery disease. In view of the diffuse nature of transplant vasculopathy known from pathologic studies, 2 PCI in transplant recipients was ini- tially considered an experimental or palliative therapy. Early results confirmed the feasibility of PCI in these patients but demonstrated discouraging restenosis rates. 3– 8 The increased volume of bare metal stents used since 1997 was associated with lower restenosis rates. 9 –14 Data on the effect of PCI on long-term graft survival diverge owing to various follow-up and time-related co- variates (e.g., conservative treatment). 9 –11,13–16 We present a large single-center experience of PCI in Htx recipients and a review of major studies. MATERIALS AND METHODS Patients and Study Design Approval of an institutional review committee was not required because this was a retrospective data analysis. Between October 1989 and December 2006, 160 adult HTx recipients (19 women; age at Htx, 47  12 years) of a total of 1,209 Htx recipients (13.2%) at our institution underwent PCI based on visual assessment of stenosis severity (75%) in 502 coronary segments during 319 catheterizations. Pa- tients were not tested for ischemia as a standard before PCI, but 80% presented because of recent signs of progression of transplant vasculopathy in tissue Doppler imaging. 17 Written informed consent was obtained from all patients. Primary success (residual stenosis 50%), recurrence of stenosis (50% stenosis at follow-up), and cardiac events (cardiac death not due to acute rejection or re-HTx) were analyzed. Angiographic follow-up was From the Departments of a Internal Medicine/Cardiology and b Cardio- thoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany. Submitted July 26, 2007; revised October 9, 2007; accepted October 9, 2007. Reprint requests: Ernst Wellnhofer, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. Telephone: 0049-30- 45932498. Fax: 0049-30-45932500. E-mail: Ewellnhofer@t-online.de Copyright © 2008 by the International Society for Heart and Lung Transplantation. 1053-2498/08/$–see front matter. doi:10.1016/ j.healun.2007.10.007 17 ALLOGRAFT VASCULOPATHY