Heart transplantation (HT) is an accepted treatment for end-stage heart failure\n(HF). Heart transplantation significantly increases survival, exercise capacity,\nquality of life and return to work in selected patients with advanced\nheart failure compared with conventional treatment. The survival rates have\nimproved with the use of new immunosuppressive drugs, with a median survival\nafter transplantation of approximately 11 years. The shortage of donor\nhearts represents a major limitation in this field. In addition many are the\nconsequences of the limited effectiveness and complications of immunosuppressive\ntherapy (i.e. antibody-mediated rejection, infection, hypertension,\nrenal failure, malignancy and coronary artery vasculopathy). In particular,\nchronic rejection may occur months to years after the transplantation and is\nreferred to as cardiac allograft vasculopathy (CAV). CAV occurs in 32% of\nthe patients after 5 years and ensuing allograft failure from CAV eventually\naccounts for 30% of recipient deaths after transplantation. Cardiac allograft\nvasculopathy, involving coronary macro- and microcirculation, is caused by\ncomplicated interplay between immunologic and non-immunologic factors\nresulting in repetitive endothelial injury and localized sustained inflammatory\nresponse. Early diagnosis of microvascular dysfunction is substantial. In this\nreview we analyze signs and symptoms of CAV presentation and the different\nmethodologies to achieve an early and precise diagnosis. We will discuss invasive\nand non-invasive diagnostic tools and their specific role in evaluating\ngraftâ??s function, morphology, the presence of coronary artery disease and\npossible microcirculation involvement.
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