Histology of a cardiac allograft biopsy 3 years after transplantation shows concentric intimal hyperplasia in coronary arteries with smooth muscle cell proliferation and lymphocytic infiltration of vessel walls without significant luminal thrombus. This finding represents:
- A Hyperacute rejection mediated by preformed antibodies
- B Acute antibody-mediated rejection with complement activation
- C Calcineurin inhibitor toxicity causing arteriolar hyalinosis
- D Cardiac allograft vasculopathy (chronic rejection) ✓
Explanation
Cardiac allograft vasculopathy (CAV) is the manifestation of chronic rejection in heart transplants and is the leading cause of graft failure beyond 1 year. It is characterized by diffuse, concentric intimal smooth muscle proliferation in all coronary arteries (unlike native atherosclerosis which is eccentric and focal). The pathogenesis involves both T-cell-mediated (cellular) and antibody-mediated (donor-specific antibodies against HLA) immune injury to the vascular endothelium, stimulating smooth muscle migration and proliferation. Patients typically do not have chest pain due to denervation of the transplanted heart, making surveillance coronary angiography essential.
Reference: Robbins & Cotran Pathologic Basis of Disease, 10th ed.
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Written and medically reviewed by the StethoPrep medical team.