Refractory angina pectoris: To transplant or not to transplant, that is the question

Abstract

Heart transplantation is the treatment of choice for many patients with end-stage heart failure (HF) who remain symptomatic even under optimal medical therapy. Although ischemic cardiomyopathy is among the main etiologies that generate the indication for heart transplantation, patients with obstructive coronary artery disease without ventricular dysfunction are not commonly referred to heart transplantation programs. Some of these patients, however, are considered by national and international guidelines as potential candidates for heart transplantation if they present with refractory angina pectoris without the possibility of myocardial revascularization. The definition of clinical refractoriness and technical feasibility for myocardial revascularization, in addition to the risks involved for the different care strategies, are not common to all services that deal with patients with severe cardiovascular diseases and heart transplantation. This report aims to discuss the case of a 42-year-old male patient with severe obstructive coronary artery disease and complex coronary anatomy, with refractory angina pectoris, referred to the heart transplant program for a combined heart-kidney transplant (patient with renal failure on dialysis and other severe comorbidities), whose care was defined and performed in a multidisciplinary manner. The patient was prepared for a high-risk cardiac intervention and had an excellent evolution after coronary artery bypass grafting with the new technique of extensive endarterectomy, under direct vision and reconstruction of the anterior descending artery. Devices for back-up mechanical circulatory support in the perioperative period and preoperative assessment for heart transplantation were part of the individualized care strategy that, fortunately, were not used. At this time, the patient is in preparation for isolated kidney transplantation. Structured, multidisciplinary care programs matured in quality and safety processes can offer care alternatives aligned with the patient's values ​​and preferences, aiming to improve the quality of life and the individual's perspective of life and guarantee the rational use of collective resources.