Abstract Body (Do not enter title and authors here):
Background:
Cardiac Allograft Vasculopathy (CAV) is commonly seen in transplanted hearts. Due to the absence of innervation, many transplanted patients have no symptoms despite extensive disease. This poses a challenge in deciding when to perform coronary interventions. We present a case of significant CAV on surveillance angiogram that posed a challenge in management.

Case:
A 67-year-old female presented for her fifth surveillance coronary angiography nine and a half years after her heart transplant. The angiogram revealed ostial right coronary artery (RCA) chronic total occlusion (CTO) with left-to-right collaterals as well as diffuse irregularities in the left anterior descending (LAD) and left circumflex arteries. The patient was asymptomatic and two years prior to that, her angiogram revealed no significant disease. Biopsies for the past nine years showed no evidence of allograft rejection. She was subsequently referred for coronary intervention.

Due to concern of CTO being a sign of rapidly progressing CAV, it was decided to undergo revascularization of the RCA. Antegrade approach was performed with guidance from contralateral injections. Three overlapping drug-eluting stents were deployed proximally-distally using intravascular ultrasound guidance. Surveillance angiography nine months later showed patent RCA stents with no significant disease otherwise. Eighteen months later, angiography demonstrated CTO of the mid LAD and patent RCA stents with mild in-stent restenosis in the most distal RCA stent. The patient remained asymptomatic.

Discussion:
CAV develops in fifty percent of transplanted hearts within 10 years and requires close surveillance. In this case, revascularization of the RCA CTO resulted in maintaining graft function for at least two additional years as the development of LAD CTO may have resulted in graft failure had the RCA CTO not been intervened upon. CTO revascularization in CAV has the potential to prolong graft viability and delay the need for re-transplantation. Further studies related to CTO revascularization, especially in asymptomatic transplanted patients, are needed to understand the impact on morbidity and mortality in this patient population.