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Di Carli MF. Clinical Value of Positron Emission Tomography Myocardial Perfusion Imaging and Blood Flow Quantification. Cardiol Clin 2023; 41:185-195. [PMID: 37003676 DOI: 10.1016/j.ccl.2023.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Myocardial blood flow (MBF) and flow reserve (MFR) measurements by PET/computed tomography provide incremental diagnostic and prognostic information over traditional quantification of ischemia and scar by myocardial perfusion imaging. A normal stress MBF and MFR (>2.0) have a very high negative predictive value for excluding high-risk obstructive coronary artery disease (CAD). These flow measurements are also used for surveillance of coronary allograft vasculopathy after heart transplantation. A global normal MFR (>2.0) identifies patients at lower clinical risk, whereas a severely reduced MFR (<1.5) identifies patients at high risk for adverse events, even among patients without regional perfusion abnormalities.
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Zhang Y, Wang F, Wu H, Yang Y, Xu W, Wang S, Chen W, Lu L. An automatic segmentation method with self-attention mechanism on left ventricle in gated PET/CT myocardial perfusion imaging. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 229:107267. [PMID: 36502547 DOI: 10.1016/j.cmpb.2022.107267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/16/2022] [Accepted: 11/23/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVES We aimed to propose an automatic segmentation method for left ventricular (LV) from 16 electrocardiogram (ECG) -gated 13N-NH3 PET/CT myocardial perfusion imaging (MPI) to improve the performance of LV function assessment. METHODS Ninety-six cases with confirmed or suspected obstructive coronary artery disease (CAD) were enrolled in this research. The LV myocardial contours were delineated by physicians as ground truth. We developed an automatic segmentation method, which introduces the self-attention mechanism into 3D U-Net to capture global information of images so as to achieve fine segmentation of LV. Three cross-validation tests were performed on each gate (64 vs. 32 for training vs. validation). The effectiveness was validated by quantitative metrics (modified hausdorff distance, MHD; dice ratio, DR; 3D MHD) as well as cardiac functional parameters (end-systolic volume, ESV; end-diastolic volume, EDV; ejection fraction, EF). Furthermore, the feasibility of the proposed method was also evaluated by intra- and inter-observers with DR and 3D-MHD. RESULTS Compared with backbone network, the proposed approach improved the average DR from 0.905 ± 0.0193 to 0.9202 ± 0.0164, and decreased the average 3D MHD from 0.4611 ± 0.0349 to 0.4304 ± 0.0339. The average relative error of LV volume between proposed method and ground truth is 1.09±3.66%, and the correlation coefficient is 0.992 ± 0.007 (P < 0.001). The EDV, ESV, EF deduced from the proposed approach were highly correlated with ground truth (r ≥ 0.864, P < 0.001), and the correlation with commercial software is fair (r ≥ 0.871, P < 0.001). DR and 3D MHD of contours and myocardium from two observers are higher than 0.899 and less than 0.5194. CONCLUSION The proposed approach is highly feasible for automatic segmentation of the LV cavity and myocardium, with potential to benefit the precision of LV function assessment.
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Affiliation(s)
- Yangmei Zhang
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China; Guangdong Provincial Key Laboratory of Medical Image Processing, Southern Medical University, Guangzhou, China
| | - Fanghu Wang
- WeiLun PET Center, Department of Nuclear Medicine, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Huiqin Wu
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China; Guangdong Provincial Key Laboratory of Medical Image Processing, Southern Medical University, Guangzhou, China
| | - Yuling Yang
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China; Guangdong Provincial Key Laboratory of Medical Image Processing, Southern Medical University, Guangzhou, China
| | - Weiping Xu
- WeiLun PET Center, Department of Nuclear Medicine, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Shuxia Wang
- WeiLun PET Center, Department of Nuclear Medicine, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Wufan Chen
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China; Guangdong Provincial Key Laboratory of Medical Image Processing, Southern Medical University, Guangzhou, China
| | - Lijun Lu
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China; Guangdong Provincial Key Laboratory of Medical Image Processing, Southern Medical University, Guangzhou, China; Pazhou Lab, Guangzhou, China.
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Wang F, Xu W, Lv W, Du D, Feng H, Zhang X, Wang S, Chen W, Lu L. Evaluation of the diagnostic value of joint PET myocardial perfusion and metabolic imaging for vascular stenosis in patients with obstructive coronary artery disease. J Nucl Cardiol 2021; 28:3070-3080. [PMID: 32440989 DOI: 10.1007/s12350-020-02160-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 04/16/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND To investigate the diagnostic value of joint PET myocardial perfusion and metabolic imaging for vascular stenosis in patients with suspected obstructive coronary artery disease (CAD). METHODS Eighty-eight patients (53 and 35 applied for training and validation, respectively) with suspected obstructive CAD were referred to 13N-NH3 PET/CT myocardial perfusion imaging (MPI) and 18F-FDG PET/CT myocardial metabolic imaging (MMI) with available coronary angiography for analysis. One semi-quantitative indicator summed rest score (SRS) and five quantitative indicators, namely, perfusion defect extent (EXT), total perfusion deficit (TPD), myocardial blood flow (MBF), scar degree (SCR), and metabolism-perfusion mismatch (MIS), were extracted from the PET rest MPI and MMI scans. Different combinations of indicators and seven machine learning methods were used to construct diagnostic models. Diagnostic performance was evaluated using the sum of four metrics (noted as sumScore), namely, area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity. RESULTS In univariate analysis, MIS outperformed other individual indicators in terms of sumScore (2.816-3.042 vs 2.138-2.908). In multivariate analysis, support vector machine (SVM) consisting of three indicators (MBF, SCR, and MIS) achieved the best performance (AUC 0.856, accuracy 0.810, sensitivity 0.838, specificity 0.757, and sumScore 3.261). This model consistently achieved significantly higher AUC compared with the SRS method for four specific subgroups (0.897, 0.839, 0.875, and 0.949 vs 0.775, 0.606, 0.713, and 0.744; P = 0.041, 0.005, 0.034 0.003, respectively). CONCLUSIONS The joint evaluation of PET rest MPI and MMI could improve the diagnostic performance for obstructive CAD. The multivariate model (MBF, SCR, and MIS) combined with SVM outperformed other methods.
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Affiliation(s)
- Fanghu Wang
- School of Biomedical Engineering and Guangdong Provincial Key Laboratory of Medical Image Processing, Southern Medical University, 1023 Shatai Road, Guangzhou, 510515, Guangdong, China
| | - Weiping Xu
- WeiLun PET Center, Department of Nuclear Medicine, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, 106 Zhongshan Second Road, Guangzhou, 510080, Guangdong, China
| | - Wenbing Lv
- School of Biomedical Engineering and Guangdong Provincial Key Laboratory of Medical Image Processing, Southern Medical University, 1023 Shatai Road, Guangzhou, 510515, Guangdong, China
| | - Dongyang Du
- School of Biomedical Engineering and Guangdong Provincial Key Laboratory of Medical Image Processing, Southern Medical University, 1023 Shatai Road, Guangzhou, 510515, Guangdong, China
| | - Hui Feng
- School of Biomedical Engineering and Guangdong Provincial Key Laboratory of Medical Image Processing, Southern Medical University, 1023 Shatai Road, Guangzhou, 510515, Guangdong, China
| | - Xiaochun Zhang
- WeiLun PET Center, Department of Nuclear Medicine, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, 106 Zhongshan Second Road, Guangzhou, 510080, Guangdong, China
| | - Shuxia Wang
- WeiLun PET Center, Department of Nuclear Medicine, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, 106 Zhongshan Second Road, Guangzhou, 510080, Guangdong, China.
| | - Wufan Chen
- School of Biomedical Engineering and Guangdong Provincial Key Laboratory of Medical Image Processing, Southern Medical University, 1023 Shatai Road, Guangzhou, 510515, Guangdong, China.
| | - Lijun Lu
- School of Biomedical Engineering and Guangdong Provincial Key Laboratory of Medical Image Processing, Southern Medical University, 1023 Shatai Road, Guangzhou, 510515, Guangdong, China.
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4
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Ortega-Legaspi JM, Bravo PE. Diagnosis and management of cardiac allograft vasculopathy. Heart 2021; 108:586-592. [PMID: 34340994 DOI: 10.1136/heartjnl-2020-318063] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 07/07/2021] [Indexed: 11/04/2022] Open
Abstract
One of the main causes of death beyond the first year after heart transplantation is cardiac allograft vasculopathy (CAV). This review summarises the current understanding of its complex pathophysiology, detection and treatment, including the available data on non-invasive imaging modalities used for screening and diagnosis. A better understanding of this entity is crucial to improving the long-term outcomes of the growing population of patients with a heart transplant.
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Affiliation(s)
- Juan M Ortega-Legaspi
- Department of Medicine, Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Paco E Bravo
- Department of Medicine, Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Nuclear Medicine, Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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5
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Abstract
Quantitative myocardial perfusion PET/CT imaging is one of the most accurate tests for diagnosis and risk stratification of patients with suspected or known CAD. The test provides a comprehensive evaluation of patients with ischemic heart disease including quantitative assessments of regional myocardial perfusion, LV volumes and ejection fraction, calcified atherosclerotic burden, and myocardial blood flow and flow reserve (MFR). A normal stress myocardial blood flow and MFR (>2.0) has a very high negative predictive value and reliably excludes high-risk obstructive CAD. A global normal MFR (>2.0) identifies patients at consistently lower clinical risk. Conversely, a severely reduced MFR (<1.5) identifies patients at high clinical risk for adverse events regardless of whether this is due to obstructive CAD, microvascular dysfunction, or a combination of the 2. On the other hand, the delineation of atherosclerotic burden with either a formal quantitative coronary calcium score or by a semiquantitative assessment of the CT transmission scan is very helpful to guide the need for intensive preventive therapies. Recent evidence suggests that patients with angiographically obstructive CAD and a severe reduction in flow reserve (<1.6) may have a prognostic advantage from revascularization. This finding awaits confirmation by randomized clinical trials.
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Affiliation(s)
- Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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6
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Bravo PE, Bergmark BA, Vita T, Taqueti VR, Gupta A, Seidelmann S, Christensen TE, Osborne MT, Shah NR, Ghosh N, Hainer J, Bibbo CF, Harrington M, Costantino F, Mehra MR, Dorbala S, Blankstein R, Desai A, Stevenson L, Givertz MM, Di Carli MF. Diagnostic and prognostic value of myocardial blood flow quantification as non-invasive indicator of cardiac allograft vasculopathy. Eur Heart J 2019; 39:316-323. [PMID: 29236988 DOI: 10.1093/eurheartj/ehx683] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 11/02/2017] [Indexed: 11/15/2022] Open
Abstract
Aims Cardiac allograft vasculopathy (CAV) is a leading cause of death in orthotopic heart transplant (OHT) survivors. Effective non-invasive screening methods are needed. Our aim was to investigate the added diagnostic and prognostic value of myocardial blood flow (MBF) to standard myocardial perfusion imaging (MPI) with positron emission tomography (PET) for CAV detection. Methods and results We studied 94 OHT recipients (prognostic cohort), including 66 who underwent invasive coronary angiography and PET within 1 year (diagnostic cohort). The ISHLT classification was used as standard definition for CAV. Positron emission tomography evaluation included semiquantitative MPI, quantitative MBF (mL/min/g), and left ventricular ejection fraction (LVEF). A PET CAV severity score (on a scale of 0-3) was modelled on the ISHLT criteria. Patients were followed for a median of 2.3 years for the occurrence of major adverse events (death, re-transplantation, acute coronary syndrome, and hospitalization for heart failure). Sensitivity, specificity, positive, and negative predictive value of semiquantitative PET perfusion alone for detecting moderate-severe CAV were 83% [52-98], 82% [69-91], 50% [27-73], and 96% [85-99], respectively {receiver operating characteristic (ROC area: 0.82 [0.70-0.95])}. These values improved to 83% [52-98], 93% [82-98], 71% [42-92], and 96% [97-99], respectively, when LVEF and stress MBF were added (ROC area: 0.88 [0.76-0.99]; P = 0.01). There were 20 major adverse events during follow-up. The annualized event rate was 5%, 9%, and 25% in patients with normal, mildly, and moderate-to-severely abnormal PET CAV grading (P < 0.001), respectively. Conclusion Multiparametric cardiac PET evaluation including quantification of MBF provides improved detection and gradation of CAV severity over standard myocardial perfusion assessment and is predictive of major adverse events.
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Affiliation(s)
- Paco E Bravo
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Cardiovascular Imaging Program, Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA
| | - Brian A Bergmark
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA
| | - Tomas Vita
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Cardiovascular Imaging Program, Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA
| | - Viviany R Taqueti
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Cardiovascular Imaging Program, Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA.,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA
| | - Ankur Gupta
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Cardiovascular Imaging Program, Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA
| | - Sara Seidelmann
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Cardiovascular Imaging Program, Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA
| | - Thomas E Christensen
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Cardiovascular Imaging Program, Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA
| | - Michael T Osborne
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA.,Department of Radiology, Cardiac MR/PET/CT Program, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.,Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Nishant R Shah
- Division of Cardiovascular Medicine, Department of Medicine, Lifespan Cardiovascular Institute, Brown University Alpert School of Medicine, 830 Chalkstone Avenue, Providence, RI 02908, USA
| | - Nina Ghosh
- Ottawa Cardiovascular Centre, 1355 Bank Street, Suite 502, Ottawa, ON K1H 8K7, Canada
| | - Jon Hainer
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Cardiovascular Imaging Program, Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA
| | - Courtney F Bibbo
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Cardiovascular Imaging Program, Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA
| | - Meagan Harrington
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Cardiovascular Imaging Program, Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA
| | - Fred Costantino
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA
| | - Mandeep R Mehra
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA
| | - Sharmila Dorbala
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Cardiovascular Imaging Program, Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA.,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA
| | - Ron Blankstein
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Cardiovascular Imaging Program, Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA.,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA
| | - Akshay Desai
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA
| | - Lynne Stevenson
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA
| | - Marcelo F Di Carli
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Cardiovascular Imaging Program, Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA.,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, ASB-L1 037-C, 75 Francis Street, Boston, MA 02115, USA
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Abstract
PURPOSE OF REVIEW Recent years have seen advances in the early detection of cardiac graft rejection. RECENT FINDINGS We review the possibilities offered by tissue Doppler imaging and speckle tracking echocardiography, cardiac magnetic resonance, cardiac computed tomography, single positron emission tomography, gene expression profiling, and quantitation of donor-derived cell-free DNA, and microRNAs. SUMMARY Noninvasive monitoring of acute and chronic rejection after cardiac transplantation is an unmet need and remains a challenge. Imaging techniques and peripheral blood biomarkers are the most commonly used approaches, and in recent years there has been great progress. Gene expression profiling seems to be useful for ruling out the presence of a moderate to severe acute cellular rejection in stable, low-risk patients. Newer monitoring tools, like donor-derived cell-free DNA or microRNA, seem to be promising for individualizing immunosuppressive therapies and better understanding the mechanisms of rejection.
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9
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Payne GA, Hage FG, Acharya D. Transplant allograft vasculopathy: Role of multimodality imaging in surveillance and diagnosis. J Nucl Cardiol 2016; 23:713-27. [PMID: 26711101 DOI: 10.1007/s12350-015-0373-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 11/27/2015] [Indexed: 01/22/2023]
Abstract
Cardiac allograft vasculopathy (CAV) is a challenging long-term complication of cardiac transplantation and remains a leading long-term cause of graft failure, re-transplantation, and death. CAV is an inflammatory vasculopathy distinct from traditional atherosclerotic coronary artery disease. Historically, the surveillance and diagnosis of CAV has been dependent on serial invasive coronary angiography with intravascular imaging. Although commonly practiced, angiography is not without significant limitations. Technological advances have provided sophisticated imaging techniques for CAV assessment. It is now possible to assess the vascular lumen, vessel wall characteristics, absolute blood flow, perfusion reserve, myocardial contractile function, and myocardial metabolism and injury in a noninvasive, expeditious manner with little risk. The current article will review key imaging modalities for the surveillance, diagnosis, and prognosis of CAV and discuss coronary physiology of transplanted hearts with emphasis on the clinical implications for provocative and vasodilator stress testing.
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Affiliation(s)
- Gregory A Payne
- Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, Tinsley Harrison Tower, Room 321, Birmingham, AL, 35294-006, USA
| | - Fadi G Hage
- Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, Tinsley Harrison Tower, Room 321, Birmingham, AL, 35294-006, USA
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Deepak Acharya
- Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, Tinsley Harrison Tower, Room 321, Birmingham, AL, 35294-006, USA.
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10
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Clemmensen TS, Eiskjær H, Løgstrup BB, Tolbod LP, Harms HJ, Bouchelouche K, Hoff C, Frøkiær J, Poulsen SH. Noninvasive Detection of Cardiac Allograft Vasculopathy by Stress Exercise Echocardiographic Assessment of Myocardial Deformation. J Am Soc Echocardiogr 2016; 29:480-90. [PMID: 26898523 DOI: 10.1016/j.echo.2016.01.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the value of noninvasive assessment of cardiac allograft vasculopathy (CAV) in heart-transplanted patients by exercise stress myocardial deformation and coronary flow reserve (CFR) assessment. METHODS Fifty-eight heart-transplanted patients underwent semisupine exercise echocardiography with assessment of left ventricular (LV) longitudinal myocardial deformation. CAV was assessed by coronary angiography and noninvasive CFR by (15)O-H2O positron emission tomographic imaging and Doppler echocardiography. Patients were divided into three groups on the basis of angiographic CAV: no CAV (n = 21), mild CAV (n = 19), and severe CAV (n = 18). RESULTS Patients with severe CAV had significantly lower LV global longitudinal strain (GLS) at rest (no CAV, -16 ± 2%; mild CAV, -15 ± 2%; severe CAV, -12 ± 4%; P < .001), failed to increase LV GLS during exercise (no CAV, -5.7 ± 2.0%; mild CAV, -3.3 ± 2.9%; severe CAV, -0.2 ± 2.8%; P < .0001), and had significantly lower echocardiographic coronary flow velocity reserve (CFVR) (no CAV, 3.2 ± 0.4; mild CAV, 2.7 ± 0.7; severe CAV, 1.8 ± 0.5; P < .0001) and PET CFR (no CAV, 3.4 ± 0.9; mild CAV, 3.1 ± 0.9; severe CAV, 1.9 ± 0.8; P < .0001). Furthermore, patients with mild CAV had significantly lower exercise LV GLS and echocardiographic CFVR than patients with no CAV. Exercise LV GLS, echocardiographic CFVR, and PET CFR were significantly correlated with the presence of severe CAV in a logistic regression model (LV GLS odds ratio, 0.71; 95% CI, 0.60-0.84; P < .0001; echocardiographic CFVR odds ratio: 0.06; 95% CI, 0.01-0.23; PET CFR odds ratio, 0.17; 95% CI, 0.07-0.46). This relation remained significant after adjustment for symptoms and time since transplantation. CONCLUSIONS Noninvasive assessment of LV longitudinal myocardial deformation during exercise is feasible and strongly associated with the presence and degree of CAV. Exercise stress myocardial deformation analysis, echocardiographic CFVR, or PET CFR may serve as a noninvasive model for the detection of CAV.
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Affiliation(s)
| | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | | | - Lars Poulsen Tolbod
- Department of Nuclear Medicine & PET Center, Aarhus University Hospital, Skejby, Denmark
| | - Hendrik J Harms
- Department of Nuclear Medicine & PET Center, Aarhus University Hospital, Skejby, Denmark
| | - Kirsten Bouchelouche
- Department of Nuclear Medicine & PET Center, Aarhus University Hospital, Skejby, Denmark
| | - Camilla Hoff
- Department of Nuclear Medicine & PET Center, Aarhus University Hospital, Skejby, Denmark
| | - Jørgen Frøkiær
- Department of Nuclear Medicine & PET Center, Aarhus University Hospital, Skejby, Denmark
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11
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Inhomogeneous myocardial stress perfusion in SPECT studies predicts future allograft dysfunction in heart transplant recipients. EJNMMI Res 2015; 5:51. [PMID: 26438347 PMCID: PMC4593982 DOI: 10.1186/s13550-015-0129-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 09/23/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Myocardial perfusion gated single photon emission computed tomography (SPECT) can be used for non-invasive detection of coronary artery stenosis and cardiac allograft vasculopathy (CAV), which is a crucial factor for the long-term survival of heart transplant (HTx) recipients. A frequently observed finding in myocardial perfusion imaging of patients after HTx is inhomogeneous myocardial perfusion. This finding is not associated with epicardial CAV, but its prognostic relevance is unclear so far. We therefore evaluated the prognosis of patients with homogeneous versus inhomogeneous myocardial stress perfusion. METHODS One hundred four HTx patients (mean 3.6 ± 2.9 years after HTx) without significant stress-induced ischemia (summed stress score ≤3) in gated SPECT and without CAV were included. Myocardial stress perfusion was visually assessed as homogeneous, moderately, or severely inhomogeneous. The mean follow-up period after SPECT was 9.4 ± 3.1 years. End points were the diagnosis of CAV, major cardiac events (MACE) or death, and the development of allograft dysfunction (left ventricular ejection fraction, LVEF <45 %). RESULTS Of all HTx patients, 24 % enrolled in this study (n = 25) presented with inhomogeneous myocardial perfusion. Compared to the patients with homogeneous perfusion, these patients were at higher risk for developing allograft dysfunction (multivariate hazard ratio, HR = 5.59). As to the development of CAV, the occurrence of MACE, or death, no statistical differences were observed between patients with homogenous and inhomogeneous perfusion. There was no correlation between myocardial perfusion pattern and prior cardiac allograft rejections. CONCLUSIONS Inhomogeneous myocardial stress perfusion in SPECT studies predicts a higher risk for future development of allograft dysfunction in HTx patients (LVEF <45 %) but is not associated with future CAV, MACE, or overall survival.
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12
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Gupta B, Jacob D, Thompson R. Imaging in patients after cardiac transplantation and in patients with ventricular assist devices. J Nucl Cardiol 2015; 22:617-38. [PMID: 25832983 DOI: 10.1007/s12350-015-0115-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 01/29/2015] [Indexed: 02/06/2023]
Abstract
The field of cardiac imaging and the management of patients with severe heart failure have advanced substantially during the past 10 years. Cardiac transplantation offers the best long-term survival with high quality of life for the patients with end stage heart failure. However, acute cardiac rejection and cardiac allograft vasculopathy (CAV) can occur post cardiac transplantation and these problems necessitate regular surveillance. The short-term success of mechanical circulatory support devices (MCSD), such as ventricular assist devices (VADs), in improving survival and quality of life has led to a dramatic growth of the patient population with these devices. The development of optimal imaging techniques and algorithms to evaluate these advanced heart failure patients is evolving and multimodality non-invasive imaging approaches and invasive techniques are commonly employed. Most of the published studies done in the transplant and VAD population are small, and biased based on the strength of the particular program, and there is a relative lack of published protocols to evaluate these patient groups. Moreover, the techniques of echocardiography, computed tomography (CT), magnetic resonance imaging, and nuclear cardiology have all progressed rapidly in recent years. There is thus a knowledge gap for cardiologists, radiologists, and clinicians, especially regarding surveillance for CAV and ideal imaging approaches for patients with VADs. The purpose of this review article is to provide an overview of different noninvasive imaging modalities used to evaluate patients after cardiac transplantation and for patients with VADs. The review focuses on the role of echocardiography, CT, and nuclear imaging in surveillance for CAV and rejection and on the assessment of ventricular structure and function, myocardial remodeling and complications for VAD patients.
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Affiliation(s)
- Bhanu Gupta
- Department of Cardiology, St. Luke's Mid America Heart Institute, 4330 Wornall Rd, Suite 2000, Kansas City, MO, USA
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Non-invasive screening for cardiac allograft vasculopathy: go small or go home? J Heart Lung Transplant 2014; 34:158-60. [PMID: 25511745 DOI: 10.1016/j.healun.2014.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 10/11/2014] [Accepted: 11/04/2014] [Indexed: 11/23/2022] Open
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DePasquale EC, Schweiger M, Ross HJ. A contemporary review of adult heart transplantation: 2012 to 2013. J Heart Lung Transplant 2014; 33:775-84. [DOI: 10.1016/j.healun.2014.04.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 03/14/2014] [Accepted: 04/30/2014] [Indexed: 02/07/2023] Open
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Everolimus therapy is associated with reduced lipoprotein-associated phospholipase A2 (Lp-Pla2) activity and oxidative stress in heart transplant recipients. Atherosclerosis 2013; 230:164-70. [PMID: 23958269 DOI: 10.1016/j.atherosclerosis.2013.07.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Revised: 07/05/2013] [Accepted: 07/10/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Several studies demonstrated decreased severity and incidence of cardiac allograft vasculopathy (CAV) in heart transplant recipients receiving immunosuppressive therapy with everolimus. However, data regarding the influence of everolimus on risk factors predisposing to CAV are hitherto limited. We here systematically evaluated cardiovascular risk factors in heart transplanted patients, who underwent conversion to everolimus or were maintained on conventional therapy with calcineurin inhibitors (CNI). METHODS 50 Patients receiving everolimus and 91 patients receiving CNI in addition to mycophenolate mofetil and low-dosed steroids were included in the study. CAV risk factors were determined in plasma or urine using standard enzymatic or immunochemical methods. RESULTS No significant differences were observed between both groups with regard to lipid (total, LDL- and HDL-cholesterol), metabolic (glucose, insulin), inflammatory (C-reactive protein, IL-6, myeloperoxidase) and cardiac (troponin I, NT-proBNP) risk factors. However, significantly lower activity of lipoprotein-associated phospholipase A2 (Lp-PLA2) and a negative correlation between the Lp-PLA2 activity and the everolimus concentration were observed in plasmas from everolimus-treated patients. Conversion to everolimus significantly lowered Lp-PLA2 activity in heart transplant recipients. Studies in vitro revealed reduced Lp-PLA2 expression in hepatocytes and macrophages pre-exposed to everolimus. In addition, reduced plasma markers of oxidative stress including oxidized LDL, 8-iso-prostaglandin F2α and protein carbonyls were noted in heart transplant recipients receiving everolimus therapy. CONCLUSION Our results suggest that everolimus specifically lowers plasma activity and cellular production of Lp-PLA2 and thereby dampens oxidative stress. These effects may additionally contribute to the reduced CAV incidence observed in heart transplant recipients receiving everolimus therapy.
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