Improved Graft Vasculopathy Following Mycophenolate Mofetil Administration in a Child

Graft vasculopathy limits survival in pediatric heart transplantation and generally leads to retransplantation, due to the technical limitations of percutaneous revascularization.1 In experimental models, rapamycin and mycophenolate mofetil (MMF) decrease intimal proliferation of graft vasculopathy. In animals, MMF is associated with a lower incidence of graft vasculopathy than azathioprine. We describe a 5-year-old boy weighing 15 kg, with blood group O-positive, who underwent heart transplantation in August 1998 because of cardiogenic shock after chickenpox. He received OKT3 induction and maintenance therapy with cyclosporine, azathioprine and prednisone. One month post-transplantation, he presented ISHLT (International Society of Heart & Lung Transplant) Grade 3A allograft rejection. Thirteen months later, graft vasculopathy was detected by coronary angiography (Figure 1A). Azathioprine was replaced with MMF (600 mg/m2 every 12 h), a statin was added and 6-monthly coronary angiographies were scheduled. The patient remained asymptomatic in subsequent outpatient follow-up visits, and showed gradual angiographic improvement (Figure 1B). Graft vasculopathy consists of intimal hyperplasia with concentric, diffuse, gradual narrowing of the epicardial and intramyocardial arteries of the transplanted heart.2 Its 5-year incidence in children is 10%-35% (angiographic diagnosis), a figure below that of adults because of the lower long-term survival, lower use of coronary angiography and utilization of younger donors in children.3 A history of allograft rejecA