Three years after orthotopic heart transplantation, a patient develops insidious heart failure. Coronary angiography appears nearly normal, but intravascular ultrasound shows diffuse concentric thickening of both epicardial and intramyocardial coronary vessels. This late complication is best described as:

• A Atherosclerotic plaque rupture with focal eccentric stenosis treated by stenting
• B Cardiac allograft vasculopathy, an immune-mediated diffuse proliferative intimal hyperplasia ✓
• C Giant cell arteritis involving the proximal coronary arteries
• D Recurrence of the original host cardiomyopathy within the graft

Explanation

Cardiac allograft vasculopathy is the leading cause of death beyond the first year after transplantation. It is a chronic vascular rejection phenomenon causing diffuse, concentric intimal proliferation along the length of epicardial and distal vessels, which makes standard angiography insensitive and justifies surveillance with IVUS or dobutamine stress echo. Unlike classic atherosclerosis it is not focal or eccentric and does not present with plaque rupture.

Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.