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Multimodality Imaging to Detect Rejection, and Cardiac Allograft Vasculopathy in Pediatric Heart Transplant Recipients—An Illustrative Review. TRANSPLANTOLOGY 2022. [DOI: 10.3390/transplantology3030025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The three most common modalities of graft surveillance in pediatric heart transplant (HT) recipients include echocardiography, coronary angiography, and endomyocardial biopsy (EMB). The survival outcomes after HT in children have improved considerably in recent years. However, allograft rejection and cardiac allograft vasculopathy remain the leading cause of death or re-transplantation. The routine surveillance by EMB and coronary angiography are invasive and risky. Newer noninvasive echocardiographic techniques, including tissue Doppler imaging (TDI), 2-D speckle tracking echocardiography, CT coronary angiography (CTCA), cardiovascular magnetic resonance (CMR), single-photon emission computed tomography (SPECT), and positron emission tomography (PET) and invasive techniques such as intravascular ultrasound (IVUS), functional flow reserve (CFR) of coronary arteries, optical coherence tomography (OCT), have emerged as powerful tools which may help early recognition of sub-clinical rejection, response to treatment, early detection, and progression of CAV. The multimodality imaging approach, including noninvasive and invasive tests, is the future for the transplanted heart to detect dysfunction, rejections, and early CAV. This review illustrates noninvasive and invasive imaging techniques currently used or could be considered for clinical use in detecting heart transplant rejection, dysfunction, and CAV in children.
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Perez MT, Rizwan R, Gauvreau K, Daly K, Deng E, Blume E, Singh TP, Chen MH. Prognostic Value of Exercise Stress Echocardiography in Pediatric Cardiac Transplant Recipients. J Am Soc Echocardiogr 2022; 35:1133-1138.e2. [PMID: 35863548 DOI: 10.1016/j.echo.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/03/2022] [Accepted: 07/07/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is a leading cause of long-term morbidity and mortality in pediatric heart transplant (HTx) recipients. Exercise stress echocardiography (ESE) has been shown to be useful in the detection of angiographically-confirmed CAD in children. However, the prognostic utility of ESE for prediction of cardiac events in HTx survivors is unknown. STUDY AIM AND HYPOTHESIS Therefore, we aim to assess if an abnormal (positive) ESE will be associated with a higher risk of future cardiovascular (CV) outcomes in pediatric HTx recipients. MATERIAL AND METHODS We conducted a retrospective review of CV outcomes of a cohort of 95 pediatric HTx recipients who underwent 188 ESE over a 10-year period. A composite endpoint for CV events including myocardial infarction, hospitalization for non-rejection heart failure, coronary revascularization, need for repeat transplantation, and death was used. Based on the interpretation of the ESE results, each ESE study was classified for this study as either positive (abnormal), or negative (normal) for ischemia. Results of the coronary angiograms performed near the time of ESE were also assessed and classified for this study as positive (abnormal) or negative (normal) for CAV according to standard HTx criteria for CAV. RESULTS 51 (27%) ESE were positive for ischemia. There was a total of 35 CV events in 23 patients. A positive ESE was associated with increased risk of any CV event [Hazard ratio [HR] 3.55, 95% CI 1.52, 8.28, and also an increased risk of CV death (HR 3.19, 95% CI 1.23, 8.28) Freedom from composite CV outcome at 1, 2, and 3 years following a positive ESE was 89.9% (CI = 77.3%, 95.7%), 81.5% (CI = 65.9%, 90.5%), and 63.2% (CI = 41.9%, 78.5%), respectively. Freedom from composite cardiovascular outcome at 1, 2, and 3 years following a negative ESE was 99.3% (94.8, 99.9), 98.4% (93.6, 99.6), and 97.0% (90.6, 99.1) respectively. No patient died within 1 year of a negative ESE. CONCLUSIONS In this largest study of ESE in pediatric HTx recipients, a positive or abnormal ESE is associated with increased future cardiovascular morbidity and mortality. Conversely, a negative ESE can help predict CV event-free survival. Even in the setting of a normal ANG, our pilot data show that an abnormal ESE may be still clinically important. Use of ESE in follow-up may improve risk stratification and management of pediatric HTx recipients.
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Affiliation(s)
- Maria T Perez
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115
| | - Raheel Rizwan
- Department of Pediatrics, Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115
| | - Kevin Daly
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115
| | - Ellen Deng
- Department of Pediatrics, Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115
| | - Elizabeth Blume
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115
| | - Tajinder P Singh
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115
| | - Ming Hui Chen
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115; Department of Pediatrics, Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115.
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Pellikka PA, Arruda-Olson A, Chaudhry FA, Chen MH, Marshall JE, Porter TR, Sawada SG. Guidelines for Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease: From the American Society of Echocardiography. J Am Soc Echocardiogr 2020; 33:1-41.e8. [DOI: 10.1016/j.echo.2019.07.001] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Semi-supine exercise stress echocardiography in children and adolescents: feasibility and safety. Pediatr Cardiol 2015; 36:633-9. [PMID: 25410823 PMCID: PMC4335126 DOI: 10.1007/s00246-014-1058-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 10/31/2014] [Indexed: 11/28/2022]
Abstract
Although exercise stress echocardiography (ESE) is a well-validated technique in adult population, its use in children is quite limited. We aimed to assess the feasibility, the safety and the reproducibility of ESE, using on-line scanning in semi-supine cyclo-ergometer protocol in a large pediatric population. Between July 2008 and January 2013, 42 patients (mean age 14 ± 3) were evaluated with a bicycle ESE performing 50 studies. ESE was successfully performed and well tolerated by all patients. None of the patients presented with adverse effects of stress-induced ischemia. HR was 82 ± 13 at rest, and 153 ± 19.1 during peak exercise. Among 544 views analyzed for grading of image quality, the visualization was optimal in 473 (87 %), suboptimal in 39, and inadequate in 32 (6 %). 37 tests were performed in patients with congenital or acquired coronary abnormality. Regional wall motion abnormalities (RWMA) were revealed in nine cases (24 %). The agreement between the two different observers showed a K index of 0.7276 (95 % CI 0.6497-0.8055) for the image quality and a K index of 0.5125 (95 % CI 0.4782-0.5468) for the RWMA analysis. Among ten patients with hypertrophic cardiomyopathy, we were able to demonstrate the new comparison of significant left ventricular outflow tract gradient (≥30 mmHg) during exercise in three patients (30 %). Bicycle stress echocardiography performed by on-line scanning during exercise is a feasible, safe, and reproducible modality in children. Further data to assess its diagnostic accuracy are, however, needed. Stress echocardiography provides a dynamic assessment of the myocardial structure and function under conditions of physiologic or pharmacologic stress.
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Dedieu N, Greil G, Wong J, Fenton M, Burch M, Hussain T. Diagnosis and management of coronary allograft vasculopathy in children and adolescents. World J Transplant 2014; 4:276-293. [PMID: 25540736 PMCID: PMC4274597 DOI: 10.5500/wjt.v4.i4.276] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 08/12/2014] [Accepted: 09/17/2014] [Indexed: 02/05/2023] Open
Abstract
Coronary allograft vasculopathy remains one of the leading causes of death beyond the first year post transplant. As a result of denervation following transplantation, patients lack ischaemic symptoms and presentation is often late when the graft is already compromised. Current diagnostic tools are rather invasive, or in case of angiography, significantly lack sensitivity. Therefore a non-invasive tool that could allow early diagnosis would be invaluable.This paper review the disease form its different diagnosis techniques,including new and less invasive diagnostic tools to its pharmacological management and possible treatments.
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Ou P, Kutty S, Khraiche D, Sidi D, Bonnet D. Acquired coronary disease in children: the role of multimodality imaging. Pediatr Radiol 2013; 43:444-53. [PMID: 22972555 DOI: 10.1007/s00247-012-2478-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 06/01/2012] [Accepted: 07/18/2012] [Indexed: 10/27/2022]
Abstract
Coronary sequelae of Kawasaki disease, post-surgical coronary lesions and cardiac allograft vasculopathy are the main causes of acquired coronary pathology in childhood. Surveillance and timely recognition of coronary problems in children who are at risk of ischemic events are imperative and noninvasive imaging is increasingly utilized for these purposes. Herein, we summarize the causes of acquired coronary disease in children and discuss the role of various imaging techniques that are available to establish the diagnosis and guide management.
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Affiliation(s)
- Phalla Ou
- Service de Radiologie Pédiatrique, Hôpital Necker-Enfants Malades, AP-HP, University Paris-Descartes, 149 rue de Sèvres, 75743, Paris Cedex 15, France.
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Hussain T, Fenton M, Peel SA, Wiethoff AJ, Taylor A, Muthurangu V, Razavi R, Botnar RM, Burch M, Greil GF. Detection and grading of coronary allograft vasculopathy in children with contrast-enhanced magnetic resonance imaging of the coronary vessel wall. Circ Cardiovasc Imaging 2012; 6:91-8. [PMID: 23223637 DOI: 10.1161/circimaging.112.975797] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Coronary allograft vasculopathy is the leading cause of late death after heart transplantation in children. It is poorly detected by conventional angiography. Intravascular ultrasound is invasive and costly. This study shows that magnetic resonance imaging (MRI) late gadolinium enhancement (LGE) of the coronary vessel wall can detect and grade coronary allograft vasculopathy. METHODS AND RESULTS Twenty-four children (10 male; age range, 9-17 years) underwent coronary angiography, intravascular ultrasound, and MRI. Maximal intimal thickness and mean intimal index were recorded. MRI included coronary magnetic resonance angiogram and LGE vessel wall imaging with 1.5 T (n=12) and 3.0 T (n=12). Ten healthy control subjects also underwent LGE MRI. Mean time posttransplantation was 5.5 years (range, 0.25-14 years). Seven patients had Stanford grade IV coronary allograft vasculopathy on intravascular ultrasound, 3 of whom had angiographic disease. Maximal intimal thickness and mean intimal index were 0.73±0.50 mm and 20.9±10.6%, respectively. On MRI, mean diameter of enhancement of vessel wall was 6.57±4.91 mm, and mean enhancement index (indexed to vessel lumen size) was 1.10±1.72. The control group showed little or no LGE. Correlation of LGE with maximal intimal thickness using the Pearson coefficient was 0.80 (P<0.001) and with mean intimal index was 0.92 (P<0.001). An MRI diameter >7.5 mm gave 86% sensitivity and 93% specificity. CONCLUSIONS LGE scores correlate well with traditional intravascular ultrasound measures. These promising early results encourage larger-scale clinical studies to investigate whether LGE MRI will allow closer follow-up and better prevention of coronary allograft vasculopathy in children.
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Utility of exercise stress echocardiography in pediatric cardiac transplant recipients: a single-center experience. J Heart Lung Transplant 2012; 31:517-23. [PMID: 22301421 DOI: 10.1016/j.healun.2011.12.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 11/18/2011] [Accepted: 12/14/2011] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Annual coronary angiography (ANG) to assess for significant epicardial coronary artery disease (CAD) is an integral part of follow-up care for pediatric cardiac transplant recipients at Children's Hospital Boston. Exercise stress echocardiography (ESE) is an important, non-invasive tool for the detection of ischemia in adults but has been rarely used in children. Therefore, the aim of this study was to assess the feasibility and utility of ESE in excluding ANG-detected epicardial CAD at our center, where ESE has been implemented since 2007. METHODS We conducted a retrospective review of all pediatric cardiac transplant recipients at our institution who had undergone ESE and ANG between January 2007 and December 2010, and with testing performed < 12 months apart. ESE results were compared against ANG. RESULTS The study cohort comprised 47 cardiac transplant recipients. One patient's ESE images were inadequate for interpretation. Of the remaining 46 patients, ESE had a sensitivity of 88.9% (95% confidence limits [CL], 51.8%, 99.7%), a specificity of 91.9% (95% CL, 71.8%, 98.3%), and a negative predictive value of 97% (95% CL, 85.1%, 99.1%) for the ANG-detected CAD. CONCLUSIONS This large, single-center study showed ESE was feasible and had a high specificity and excellent negative predictive value in excluding epicardial CAD in pediatric cardiac transplant recipients. Future prospective, large-scale studies are needed to confirm these findings and help identify a subset of children for whom a negative ESE could decrease the frequency of routine ANG.
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Aiyagari R, Nika M, Gurney JG, Donohue JE, Zamberlan MC, King K, Crowley DC, Gajarski RJ. Association of Pediatric Heart Transplant Coronary Vasculopathy with Abnormal Hemodynamic Measures. CONGENIT HEART DIS 2011; 6:128-33. [DOI: 10.1111/j.1747-0803.2010.00470.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA, Madsen J, Parameshwar J, Starling RC, Uber PA. International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. J Heart Lung Transplant 2010; 29:717-27. [PMID: 20620917 DOI: 10.1016/j.healun.2010.05.017] [Citation(s) in RCA: 625] [Impact Index Per Article: 44.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Accepted: 05/22/2010] [Indexed: 01/14/2023] Open
Abstract
The development of cardiac allograft vasculopathy remains the Achilles heel of cardiac transplantation. Unfortunately, the definitions of cardiac allograft vasculopathy are diverse, and there are no uniform international standards for the nomenclature of this entity. This consensus document, commissioned by the International Society of Heart and Lung Transplantation Board, is based on best evidence and clinical consensus derived from critical analysis of available information pertaining to angiography, intravascular ultrasound imaging, microvascular function, cardiac allograft histology, circulating immune markers, non-invasive imaging tests, and gene-based and protein-based biomarkers. This document represents a working formulation for an international nomenclature of cardiac allograft vasculopathy, similar to the development of the system for adjudication of cardiac allograft rejection by histology.
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Affiliation(s)
- Mandeep R Mehra
- ISHLT Working Group on Classification of Cardiac Allograft Vasculopathy commissioned by the Education Committee and Board of Directors of the Society.
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Abd-Allah S, Checchia PA. Heart Transplantation. CARDIOVASCULAR PEDIATRIC CRITICAL ILLNESS AND INJURY 2009:1-22. [DOI: 10.1007/978-1-84800-923-3_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Dipchand AI, Bharat W, Manlhiot C, Safi M, Lobach NE, McCrindle BW. A prospective study of dobutamine stress echocardiography for the assessment of cardiac allograft vasculopathy in pediatric heart transplant recipients. Pediatr Transplant 2008; 12:570-6. [PMID: 18363614 DOI: 10.1111/j.1399-3046.2007.00861.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Transplant CAV is the leading cause of graft loss beyond one yr post-heart transplant. Diagnosis can be challenging and the previous "gold standard," coronary ANG, tends to underestimate disease. The purpose of this study was to relate DSE to ANG for the diagnosis of CAV. Prospective annual DSE at a single centre on all heart transplant patients (1999-2006) were compared with results from routine coronary angiograms. Progression of CAV over time as determined by DSE and ANG and associated factors were sought through logistic regression models adjusted for repeated measures. There were 102 heart transplant patients (54 males) transplanted between 1989 and 2006. Median age at transplant was 17 months (0-16.6 yr). The initial DSE was at a median of 10-months post-transplantation. There was a high correlation between an abnormal DSE and an abnormality on ANG (p = 0.002). There was an increased probability of an abnormal DSE with increasing grade of CAV as assessed by ANG (p < 0.001). Factors associated with an abnormal DSE included older age at transplant (p = 0.04), higher grade of rejection (p = 0.002), higher total cholesterol (p = 0.04), higher LDL (p < 0.05), and older age at the time of DSE (p = 0.002). DSE result was not related to HDL, triglyceride or homocysteine levels, or to steroid or statin use. The probability of an abnormal DSE result increases with increasing angiographic grade of CAV, and thus DSE may be used for initial screening for CAV with ANG reserved for confirmation and grading. Patients transplanted at an older age and those with a greater history of rejection were at higher risk of a positive DSE and may require increased surveillance for CAV.
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Affiliation(s)
- Anne I Dipchand
- Labatt Family Heart Centre, Hospital for Sick Children and Department of Pediatrics, University of Toronto, Toronto, ON, Canada.
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Zhang J, Krassilnikova S, Gharaei AA, Fassaei HR, Esmailzadeh L, Asadi A, Edwards DS, Harris TD, Azure M, Tellides G, Sinusas AJ, Zaret BL, Bender JR, Sadeghi MM. Alphavbeta3-targeted detection of arteriopathy in transplanted human coronary arteries: an autoradiographic study. FASEB J 2005; 19:1857-9. [PMID: 16150802 DOI: 10.1096/fj.05-4130fje] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Graft arteriopathy (GA), characterized by diffuse concentric narrowing of coronary arteries, is the major cause of late graft failure in cardiac transplantation. alphavbeta3 Integrin is up-regulated in proliferating vascular cells and may constitute an appropriate target for imaging GA. We used a human/mouse chimeric model of GA, in which segments of human coronary artery were transplanted to severe combined immunodeficiency mice, followed by reconstitution with allogeneic human peripheral blood mononuclear cells (PBMC). This led to vascular remodeling characterized by neointima formation over a period of 4 wk. alphavbeta3 expression in the graft was minimal in animals without PBMC, considerably increased by 2 wk, and decreased toward baseline by 4 wk after PBMC reconstitution. Cell proliferation was maximal at 2 wk, correlating with peak alphavbeta3 expression. RP748, an 111In-labeled alphavbeta3 (active conformation)-targeted radiotracer was injected into groups of 5 recipients at 0, 2, and 4 wk after PBMC reconstitution. Relative uptakes, defined as autoradiographic intensity in the graft/native aortas closely tracked the proliferative process. Specificity of uptake was demonstrated using excess nonlabeled tracer. In conclusion, alphavbeta3 integrin is transiently up-regulated (and activated) in GA and may be targeted by RP748 for detection of the proliferative process in early GA.
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Affiliation(s)
- Jiasheng Zhang
- Raymond and Beverly Sackler Cardiovascular Molecular Imaging Laboratory, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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