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Gupta R, Bermudez F, Vora T, Homayouni N, Weissman G, Kadakkal A, Afari-Armah N, Rao S, Lam PH, Rodrigo ME, Hofmeyer M, Krishnan M, Balsara K, Najjar SS, Sheikh FH. Surveillance Imaging and Management of Cardiac Sarcoidosis After Advanced Heart Failure Therapies. Am J Cardiol 2024; 222:35-38. [PMID: 38663574 DOI: 10.1016/j.amjcard.2024.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 04/20/2024] [Accepted: 04/20/2024] [Indexed: 05/07/2024]
Affiliation(s)
- Richa Gupta
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, District of Columbia; School of Medicine, Georgetown University, Washington, DC, District of Columbia
| | - Francisca Bermudez
- School of Medicine, Georgetown University, Washington, DC, District of Columbia
| | - Tania Vora
- Department of Cardiology, MedStar Health, Baltimore, Maryland
| | - Navid Homayouni
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, District of Columbia; School of Medicine, Georgetown University, Washington, DC, District of Columbia
| | - Gaby Weissman
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, District of Columbia; School of Medicine, Georgetown University, Washington, DC, District of Columbia
| | - Ajay Kadakkal
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, District of Columbia
| | - Nana Afari-Armah
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, District of Columbia; School of Medicine, Georgetown University, Washington, DC, District of Columbia
| | - Sriram Rao
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, District of Columbia; School of Medicine, Georgetown University, Washington, DC, District of Columbia
| | - Phillip H Lam
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, District of Columbia; School of Medicine, Georgetown University, Washington, DC, District of Columbia
| | - Maria E Rodrigo
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, District of Columbia
| | - Mark Hofmeyer
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, District of Columbia; School of Medicine, Georgetown University, Washington, DC, District of Columbia
| | - Mrinalini Krishnan
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, District of Columbia; School of Medicine, Georgetown University, Washington, DC, District of Columbia
| | - Keki Balsara
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, District of Columbia; School of Medicine, Georgetown University, Washington, DC, District of Columbia
| | - Samer S Najjar
- School of Medicine, Georgetown University, Washington, DC, District of Columbia; Department of Cardiology, MedStar Health, Baltimore, Maryland
| | - Farooq H Sheikh
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, District of Columbia; School of Medicine, Georgetown University, Washington, DC, District of Columbia.
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2
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Anand S, Alnsasra H, LeMond LM, Shrivastava S, Asleh R, Rosenbaum A, Kobrossi S, Mohananey A, Murphy K, Smith BH, Kushwaha S, Steidley DE, Clavell A, Young P, Pereira NL. Cardiac magnetic resonance imaging in heart transplant recipients with biopsy-negative graft dysfunction. ESC Heart Fail 2024; 11:1594-1601. [PMID: 38379022 PMCID: PMC11098666 DOI: 10.1002/ehf2.14681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/09/2023] [Accepted: 12/27/2023] [Indexed: 02/22/2024] Open
Abstract
AIMS Graft dysfunction (GD) after heart transplantation (HTx) can develop without evidence of cell- or antibody-mediated rejection. Cardiac magnetic resonance imaging (CMR) has an evolving role in detecting rejection; however, its role in biopsy-negative GD has not been described. This study examines CMR findings, evaluates outcomes based on CMR results, and seeks to identify the possibility of rejection missed through endomyocardial biopsy by using CMR in HTx recipients with biopsy-negative GD. METHODS AND RESULTS HTx recipients with GD [defined as a decrease in left ventricular ejection fraction (LVEF) by >5% and LVEF < 50%] in the absence of rejection by biopsy or allograft vasculopathy and who underwent CMR were included in the study. The primary outcome was a composite of all-cause mortality, re-transplantation, or persistent LVEF < 50%. Overall, 34 HTx recipients developed biopsy-negative GD and underwent CMR. Left ventricular late gadolinium enhancement (LGE) on CMR was observed in 16 patients with two distinct patterns: diffuse epicardial (n = 13) and patchy (n = 3) patterns. Patients with LGE developed GD later after HTx [4 (1.4-6.8) vs. 0.8 (0.3-1.2) years, P < 0.001], were more often symptomatic (88% vs. 56%, P = 0.06), and had greater haemodynamic derangement (pulmonary capillary wedge pressure: 19 ± 7 vs. 13 ± 3 mmHg, P = 0.002) as compared with those without LGE. No significant difference was observed in the primary composite outcome between patients with LGE and those without LGE (50% vs. 38% of patients with events, P = 0.515). During a median follow-up of 3.8 years, mean LVEF improved similarly in the LGE-negative (37-55%) and LGE-positive groups (32-55%) (P = 0.16). CONCLUSIONS Biopsy-negative GD occurs with and without LGE when assessed by CMR, indicative of possible rejection/inflammation occurring only in a subset of patients. Irrespective of LGE, LVEF improvement occurs in most GD patients, suggesting that other neurohormonal or immunomodulatory mechanisms may also contribute to GD development.
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Affiliation(s)
- Senthil Anand
- Department of Cardiovascular MedicineMayo Clinic ArizonaScottsdaleAZUSA
| | - Hilmi Alnsasra
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | - Lisa M. LeMond
- Department of Cardiovascular MedicineMayo Clinic ArizonaScottsdaleAZUSA
| | | | - Rabea Asleh
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | | | - Semaan Kobrossi
- Department of Cardiovascular MedicineMayo Clinic ArizonaScottsdaleAZUSA
| | | | - Katie Murphy
- Department of Cardiovascular MedicineMayo Clinic ArizonaScottsdaleAZUSA
| | - Byron H. Smith
- Department of Quantitative Health SciencesMayo ClinicRochesterMNUSA
| | - Sudhir Kushwaha
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | - David E. Steidley
- Department of Cardiovascular MedicineMayo Clinic ArizonaScottsdaleAZUSA
| | - Alfredo Clavell
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | | | - Naveen L. Pereira
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
- Department of Molecular Pharmacology and Experimental TherapeuticsMayo ClinicRochesterMNUSA
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3
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Lawson AA, Watanabe K, Griffin L, Laternser C, Markl M, Rigsby CK, Sojka M, Robinson JD, Husain N. Late-gadolinium enhancement is common in older pediatric heart transplant recipients and is associated with lower ejection fraction. J Cardiovasc Magn Reson 2023; 25:61. [PMID: 37932797 PMCID: PMC10626738 DOI: 10.1186/s12968-023-00971-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 10/19/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Chronic graft failure and cumulative rejection history in pediatric heart transplant recipients (PHTR) are associated with myocardial fibrosis on endomyocardial biopsy (EMB). Cardiovascular magnetic resonance imaging (CMR) is a validated, non-invasive method to detect myocardial fibrosis via the presence of late gadolinium enhancement (LGE). In adult heart transplant recipients, LGE is associated with increased risk of future adverse clinical events including hospitalization and death. We describe the prevalence, pattern, and extent of LGE on CMR in a cohort of PHTR and its associations with recipient and graft characteristics. METHODS This was a retrospective study of consecutive PHTR who underwent CMR over a 6-year period at a single center. Two independent reviewers assessed the presence and distribution of left ventricular (LV) LGE using the American Heart Association (AHA) 17-segment model. LGE quantification was performed on studies with visible fibrosis (LGE+). Patient demographics, clinical history, and CMR-derived volumetry and ejection fractions were obtained. RESULTS Eighty-one CMR studies were performed on 59 unique PHTR. Mean age at CMR was 14.8 ± 6.2 years; mean time since transplant was 7.3 ± 5.0 years. The CMR indication was routine surveillance (without a clinical concern based on laboratory parameters, echocardiography, or cardiac catheterization) in 63% (51/81) of studies. LGE was present in 36% (29/81) of PHTR. In these LGE + studies, patterns included inferoseptal in 76% of LGE + studies (22/29), lateral wall in 41% (12/29), and diffuse, involving > 4 AHA segments, in 21% (6/29). The mean LV LGE burden as a percentage of myocardial mass was 18.0 ± 9.0%. When reviewing only the initial CMR per PHTR (n = 59), LGE + patients were older (16.7 ± 2.9 vs. 12.8 ± 4.6 years, p = 0.001), with greater time since transplant (8.3 ± 5.4 vs. 5.7 ± 3.9 years, p = 0.041). These patients demonstrated higher LV end-systolic volume index (LVESVI) (34.7 ± 11.7 vs. 28.7 ± 6.1 ml/m2, p = 0.011) and decreased LV ejection fraction (LVEF) (56.2 ± 8.1 vs. 60.6 ± 5.3%, p = 0.015). There were no significant differences in history of moderate/severe rejection (p = 0.196) or cardiac allograft vasculopathy (CAV) (p = 0.709). CONCLUSIONS LV LGE was present in approximately one third of PHTR, more commonly in older patients with longer time since transplantation. Grafts with LGE have lower LVEF. CMR-derived LGE may aid in surveillance of chronic graft failure in PHTR.
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Affiliation(s)
- Andrew A Lawson
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Kae Watanabe
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Lindsay Griffin
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Christina Laternser
- Center for Cardiovascular Innovation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Michael Markl
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Cynthia K Rigsby
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Melanie Sojka
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joshua D Robinson
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nazia Husain
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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4
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 92] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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5
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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6
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Abbasi MA, Blake AM, Sarnari R, Lee D, Anderson AS, Ghafourian K, Khan SS, Vorovich EE, Rich JD, Wilcox JE, Yancy CW, Carr JC, Markl M. Multiparametric Cardiac Magnetic Resonance Imaging Detects Altered Myocardial Tissue and Function in Heart Transplantation Recipients Monitored for Cardiac Allograft Vasculopathy. J Cardiovasc Imaging 2022; 30:263-275. [PMID: 36280267 PMCID: PMC9592247 DOI: 10.4250/jcvi.2022.0003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/26/2022] [Accepted: 05/02/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is a complication beyond the first-year post-heart transplantation (HTx). We aimed to test the utility of cardiac magnetic resonance (CMR) to detect functional/structural changes in HTx recipients with CAV. METHODS Seventy-seven prospectively recruited HTx recipients beyond the first-year post-HTx and 18 healthy controls underwent CMR, including cine imaging of ventricular function and T1- and T2-mapping to assess myocardial tissue changes. Data analysis included quantification of global cardiac function and regional T2, T1 and extracellular volume based on the 16-segment model. International Society for Heart and Lung Transplantation criteria was used to adjudicate CAV grade (0–3) based on coronary angiography. RESULTS The majority of HTx recipients (73%) presented with CAV (1: n = 42, 2/3: n = 14, 0: n = 21). Global and segmental T2 (49.5 ± 3.4 ms vs 50.6 ± 3.4 ms, p < 0.001;16/16 segments) were significantly elevated in CAV-0 compared to controls. When comparing CAV-2/3 to CAV-1, global and segmental T2 were significantly increased (53.6 ± 3.2 ms vs. 50.6 ± 2.9 ms, p < 0.001; 16/16 segments) and left ventricular ejection fraction was significantly decreased (54 ± 9% vs. 59 ± 9%, p < 0.05). No global, structural, or functional differences were seen between CAV-0 and CAV-1. CONCLUSIONS Transplanted hearts display functional and structural alteration compared to native hearts, even in those without evidence of macrovasculopathy (CAV-0). In addition, CMR tissue parameters were sensitive to changes in CAV-1 vs. 2/3 (mild vs. moderate/severe). Further studies are warranted to evaluate the diagnostic value of CMR for the detection and classification of CAV.
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Affiliation(s)
- Muhannad A. Abbasi
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Allison M. Blake
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Roberto Sarnari
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Daniel Lee
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Allen S. Anderson
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Kambiz Ghafourian
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Sadiya S. Khan
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Esther E. Vorovich
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Jonathan D. Rich
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Jane E. Wilcox
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Clyde W. Yancy
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - James C. Carr
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael Markl
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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7
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Husain N, Watanabe K, Berhane H, Gupta A, Markl M, Rigsby CK, Robinson JD. Multi-parametric cardiovascular magnetic resonance with regadenoson stress perfusion is safe following pediatric heart transplantation and identifies history of rejection and cardiac allograft vasculopathy. J Cardiovasc Magn Reson 2021; 23:135. [PMID: 34809650 PMCID: PMC8607604 DOI: 10.1186/s12968-021-00803-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 08/10/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The progressive risk of graft failure in pediatric heart transplantation (PHT) necessitates close surveillance for rejection and coronary allograft vasculopathy (CAV). The current gold standard of surveillance via invasive coronary angiography is costly, imperfect and associated with complications. Our goal was to assess the safety and feasibility of a comprehensive multi-parametric CMR protocol with regadenoson stress perfusion in PHT and evaluate for associations with clinical history of rejection and CAV. METHODS We performed a retrospective review of 26 PHT recipients who underwent stress CMR with tissue characterization and compared with 18 age-matched healthy controls. CMR protocol included myocardial T2, T1 and extracellular volume (ECV) mapping, late gadolinium enhancement (LGE), qualitative and semi-quantitative stress perfusion (myocardial perfusion reserve index; MPRI) and strain imaging. Clinical, demographics, rejection score and CAV history were recorded and correlated with CMR parameters. RESULTS Mean age at transplant was 9.3 ± 5.5 years and median duration since transplant was 5.1 years (IQR 7.5 years). One patient had active rejection at the time of CMR, 11/26 (42%) had CAV 1 and 1/26 (4%) had CAV 2. Biventricular volumes were smaller and cardiac output higher in PHT vs. healthy controls. Global T1 (1053 ± 42 ms vs 986 ± 42 ms; p < 0.001) and ECV (26.5 ± 4.0% vs 24.0 ± 2.7%; p = 0.017) were higher in PHT compared to helathy controls. Significant relationships between changes in myocardial tissue structure and function were noted in PHT: increased T2 correlated with reduced LVEF (r = - 0.57, p = 0.005), reduced global circumferential strain (r = - 0.73, p < 0.001) and reduced global longitudinal strain (r = - 0.49, p = 0.03). In addition, significant relationships were noted between higher rejection score and global T1 (r = 0.38, p = 0.05), T2 (r = 0.39, p = 0.058) and ECV (r = 0.68, p < 0.001). The presence of even low-grade CAV was associated with higher global T1, global ECV and maximum segmental T2. No major side effects were noted with stress testing. MPRI was analyzed with good interobserver reliability and was lower in PHT compared to healthy controls (0.69 ± - 0.21 vs 0.94 ± 0.22; p < 0.001). CONCLUSION In a PHT population with low incidence of rejection or high-grade CAV, CMR demonstrates important differences in myocardial structure, function and perfusion compared to age-matched healthy controls. Regadenoson stress perfusion CMR could be safely and reliably performed. Increasing T2 values were associated with worsening left ventricular function and increasing T1/ECV values were associated with rejection history and low-grade CAV. These findings warrant larger prospective studies to further define the role of CMR in PHT graft surveillance.
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Affiliation(s)
- Nazia Husain
- Department of Cardiology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, USA
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Kae Watanabe
- Department of Cardiology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, USA
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Haben Berhane
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Chicago, USA
| | - Aditi Gupta
- Lincoln Medical and Mental Health Center, Bronx, NY USA
| | - Michael Markl
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Chicago, USA
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Cynthia K. Rigsby
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, USA
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, USA
- Department of Medical Imaging, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, USA
| | - Joshua D. Robinson
- Department of Cardiology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, USA
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, USA
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, USA
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8
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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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9
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Spartalis M, Spartalis E, Siasos G. Cardiac allograft vasculopathy after heart transplantation: Pathophysiology, detection approaches, prevention, and treatment management. Trends Cardiovasc Med 2021; 32:333-338. [PMID: 34303800 DOI: 10.1016/j.tcm.2021.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 01/06/2023]
Abstract
Cardiac allograft vasculopathy (CAV) continues to be a significant risk factor for the recipient's long-term survival following heart transplantation. Our knowledge of its etiology is constantly changing as new imaging techniques provide direct insight into the disease's natural history. CAV identification continues to be difficult since symptoms may be varied or nonexistent. Due to the irreversible nature of the disease, early diagnosis is critical to halting development. Prognostic tools and biomarkers have proliferated as a result of advancements in diagnostic techniques. Simultaneously, pharmaceutical advancements have aided in the amelioration of the disease's progressive progression.
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Affiliation(s)
- Michael Spartalis
- Division of Cardiology, San Raffaele University Hospital, 60 Via Olgettina, Milan 20132, Italy.
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research, University of Athens, Medical School, Athens, Greece
| | - Gerasimos Siasos
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Medical School, 11527 Athens, Greece
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10
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Stoiber L, Schoenrath F, Knosalla C, Milting H, Klingel K, Tschöpe C, Tanacli R, Gebker R, Berger A, Pieske B, Kelle S. Case Report: Early Transplant Rejection of a Methanol-Intoxicated Donor Heart in a Young Female Patient. A Diagnostic Approach With CMR, Cardiac Biopsy, and Genetic Risk Assessment. Front Immunol 2021; 11:575635. [PMID: 33692775 PMCID: PMC7938323 DOI: 10.3389/fimmu.2020.575635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 12/31/2020] [Indexed: 11/25/2022] Open
Abstract
This case report describes the contributions of multimodality imaging, cardiac biopsy, and genetic sequencing to the diagnosis and management of heart transplant rejection in a 23-year old patient with dilated cardiomyopathy.
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Affiliation(s)
- Lukas Stoiber
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Christoph Knosalla
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Hendrik Milting
- Erich and Hanna Klessmann Institute for Cardiovascular Research & Development (EHKI), Heart and Diabetes Center North Rine-Westphalia (NRW), University Hospital of the Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Karin Klingel
- Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tübingen, Tübingen, Germany
| | - Carsten Tschöpe
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology, Charité University Medicine Berlin, Berlin, Germany
| | - Radu Tanacli
- Department of Internal Medicine and Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Rolf Gebker
- Department of Internal Medicine and Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Alexander Berger
- Department of Internal Medicine and Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, German Heart Center Berlin, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology, Charité University Medicine Berlin, Berlin, Germany
| | - Sebastian Kelle
- Department of Internal Medicine and Cardiology, German Heart Center Berlin, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology, Charité University Medicine Berlin, Berlin, Germany
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11
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“Cardiac allograft vasculopathy: Pathogenesis, diagnosis and therapy”. Transplant Rev (Orlando) 2020; 34:100569. [DOI: 10.1016/j.trre.2020.100569] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/19/2020] [Indexed: 01/06/2023]
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12
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Advances and New Insights in Post-Transplant Care: From Sequencing to Imaging. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00828-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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13
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Ibrahim MM, Fang JC. Magnetic Resonance Imaging of Cardiac Allografts: What's Next? Circ Cardiovasc Imaging 2019; 12:e009784. [PMID: 31610690 DOI: 10.1161/circimaging.119.009784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Majd Mark Ibrahim
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City
| | - James C Fang
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City
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14
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Hughes A, Okasha O, Farzaneh-Far A, Kazmirczak F, Nijjar PS, Velangi P, Akçakaya M, Martin CM, Shenoy C. Myocardial Fibrosis and Prognosis in Heart Transplant Recipients. Circ Cardiovasc Imaging 2019; 12:e009060. [PMID: 31610691 DOI: 10.1161/circimaging.119.009060] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Myocardial fibrosis is a well-described histopathologic feature in heart transplant recipients. Whether myocardial fibrosis in heart transplant recipients is independently associated with clinical outcomes is unclear. We sought to determine whether myocardial fibrosis on late gadolinium enhancement cardiovascular magnetic resonance imaging in heart transplant recipients was independently associated with all-cause death or major adverse cardiac outcomes in the long-term. METHODS Using a cohort of consecutive heart transplant recipients that had cardiovascular magnetic resonance imaging, we determined the prevalence and the patterns of myocardial fibrosis and analyzed associations between myocardial fibrosis and a composite end point of all-cause death or major adverse cardiac events: retransplantation, nonfatal myocardial infarction, coronary revascularization, and heart failure hospitalization. RESULTS One hundred and fifty-two heart transplant recipients (age, 54±15 years; 29% women; 5.0±5.4 years after heart transplantation) were included. Myocardial fibrosis was present in 18% (37% infarct pattern, 41% noninfarct pattern, and 22% both). Its prevalence was positively associated with cardiac allograft vasculopathy grade. With a median follow-up of 2.6 years, myocardial fibrosis was independently associated with all-cause death or major adverse cardiac events (hazard ratio, 2.88; 95% CI, 1.59-5.23; P<0.001) after adjustment for cardiac allograft vasculopathy, history of rejection, time since transplantation, left ventricular ejection fraction, and indexed right ventricular end-diastolic volume. Every 1% increase in myocardial fibrosis was independently associated with a 6% higher hazard for all-cause death or major adverse cardiac events (hazard ratio, 1.06; 95% CI, 1.03-1.09; P<0.001). The addition of myocardial fibrosis variables to models with cardiac allograft vasculopathy, history of rejection, time since transplantation, left ventricular ejection fraction, and indexed right ventricular end-diastolic volume resulted in significant improvements in model fit, suggesting incremental prognostic value. CONCLUSIONS In heart transplant recipients, myocardial fibrosis is seen on late gadolinium enhancement cardiovascular magnetic resonance imaging in 18%. Both the presence and the extent of myocardial fibrosis are independently associated with the long-term risk of all-cause death or major adverse cardiac events.
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Affiliation(s)
- Andrew Hughes
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN (A.H., O.O., F.K., P.S.N., P.V., C.M.M., C.S.)
| | - Osama Okasha
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN (A.H., O.O., F.K., P.S.N., P.V., C.M.M., C.S.)
| | - Afshin Farzaneh-Far
- Section of Cardiology, Department of Medicine, University of Illinois at Chicago, Chicago, IL (A.F.-F.)
| | - Felipe Kazmirczak
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN (A.H., O.O., F.K., P.S.N., P.V., C.M.M., C.S.)
| | - Prabhjot S Nijjar
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN (A.H., O.O., F.K., P.S.N., P.V., C.M.M., C.S.)
| | - Pratik Velangi
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN (A.H., O.O., F.K., P.S.N., P.V., C.M.M., C.S.)
| | - Mehmet Akçakaya
- Department of Electrical and Computer Engineering and Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, MN (M.A.)
| | - Cindy M Martin
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN (A.H., O.O., F.K., P.S.N., P.V., C.M.M., C.S.)
| | - Chetan Shenoy
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN (A.H., O.O., F.K., P.S.N., P.V., C.M.M., C.S.)
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15
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Abstract
The assessment of pediatric patients after orthotropic heart transplantation (OHT) relies heavily on non-invasive imaging. Because of the potential risks associated with cardiac catheterization, expanding the role of non-invasive imaging is appealing. Echocardiography is fast, widely available, and can provide an accurate assessment of chamber sizes and function. Advanced echocardiographic methods, such as myocardial deformation, have potential to assess for acute rejection or cardiac allograft vasculopathy (CAV). While not currently part of routine care, cardiac magnetic resonance imaging (CMR) and computed tomography may potentially aid in the detection of graft complications following OHT. In particular, CMR tissue characterization holds promise for diagnosing rejection, while quantitative perfusion and myocardial late gadolinium enhancement may have a role in the detection of CAV. This review will evaluate standard and novel methods for non-invasive assessment of pediatric patients after OHT.
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Affiliation(s)
- Jonathan H Soslow
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Margaret M Samyn
- Medical College of Wisconsin, Pediatrics (Cardiology), Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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16
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Watanabe K, Schäfer M, Cassidy C, Miyamoto SD, Jone PN. Right atrial function in pediatric heart transplant patients by echocardiographic strain measurements. Pediatr Transplant 2019; 23:e13383. [PMID: 30866164 DOI: 10.1111/petr.13383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 12/13/2018] [Accepted: 01/21/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND CAV is a major cause of mortality in PHTx patients. Research on echocardiographic indices to detect CAV focuses primarily on ventricular function and less is known about RAF. Thus, we primarily sought to evaluate RAF in PHTx patients with CAV. For secondary analysis, we compared RAF between PHTx patients and control patients and evaluated RAF with respect to rejection and surgical type. METHODS We retrospectively evaluated echocardiography derived RA strain indices in recipients <18 years old and >1 year from time of transplant. The RA strain phases included, reservoir (εs), conduit (εe), pump (εa), and respective strain rate indices (SRs, SRe, SRa). RESULTS There were 36 PHTx patients and 14 age-, sex-matched control patients. There was a significant reduction in εs, εe, SRs, and SRe (P < 0.001) in the PHTx patients when compared to controls. There was no difference between the CAV (+) and CAV (-) patients with respect to RAF indices. Furthermore, εs, εe, and SRe (P < 0.05) were lower in patients with acute rejection (n = 7) compared to those without (n = 26). Patients with a bi-atrial anastomosis (n = 14) had decreased εs, εa, SRs, SRa (P < 0.05), compared to bi-caval anastomosis (n = 24). CONCLUSION PHTx patients have decreased RAF compared to healthy children. RAF does not differentiate PHTx patients based on the presence of CAV. RAF is also decreased in PHTx patients with rejection and in those transplanted with a bi-atrial anastomosis.
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Affiliation(s)
- Kae Watanabe
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado.,Division of Cardiology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michal Schäfer
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Courtney Cassidy
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Shelley D Miyamoto
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Pei-Ni Jone
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
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17
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Beitzke D, Wielandner A, Wollenweber T, Vraka C, Pichler V, Uyanik-Uenal K, Zuckermann A, Greiser A, Hacker M, Loewe C. Assessment of sympathetic reinnervation after cardiac transplantation using hybrid cardiac PET/MRI: A pilot study. J Magn Reson Imaging 2019; 50:1326-1335. [PMID: 30892777 PMCID: PMC6766915 DOI: 10.1002/jmri.26722] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 03/01/2019] [Accepted: 03/02/2019] [Indexed: 12/12/2022] Open
Abstract
Background Sympathetic reinnervation after heart transplantation (HTX) is a known phenomenon, which has an impact on patient heart rate variability and exercise capacity. The impact of reinnervation on myocardial structure has not been evaluated yet. Propose To evaluate the feasibility of simultaneous imaging of cardiac reinnervation and cardiac structure using a hybrid PET/MRI system. Study type Prospective / pilot study. Subjects Ten patients, 4–21 years after cardiac transplantation. Field Strength/Sequence 3 T hybrid PET/MRI system. Cine SSFP, T1 mapping (modified Look–Locker inversion recovery sequence) pre/postcontrast as well as dynamic [11C]meta‐hydroxyephedrine ([11C]mHED) PET. Assessment All MRI and PET parameters were evaluated by experienced readers using dedicated postprocessing software packages for cardiac MRI and PET. For all parameters a 16‐segment model for the left ventricle was applied. Statistical Tests Mann–Whitney U‐test; Spearman correlations. Results Thirty‐six of 160 myocardial segments showed evidence of reinnervation by PET. On a segment‐based analysis, mean native T1 relaxation times were nonsignificantly altered in segments with evidence of reinnervation (1305 ± 151 msec vs. 1270 ± 112 msec; P = 0.1), whereas mean extracellular volume (ECV) was significantly higher in segments with evidence of reinnervation (35.8 ± 11% vs. 30.9 ± 7%; P = 0.019). There were no significant differences in wall motion (WM) and wall thickening (WT) between segments with or without reinnervation (mean WM: 7.6 ± 4 mm vs. group B: 9.3 ± 7 mm [P = 0.13]; WT: 79 ± 63% vs. 94 ± 74% [P = 0.27]) under resting conditions. Data Conclusion The assessment of cardiac reinnervation using a hybrid PET/MRI system is feasible. Segments with evidence of reinnervation by PET showed nonsignificantly higher T1 relaxation times and a significantly higher ECV, suggesting a higher percentage of diffuse fibrosis in these segments, without impairment of rest WM and WT. Level of Evidence: 3 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2019;50:1326–1335.
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Affiliation(s)
- Dietrich Beitzke
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Cardiovascular and Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - Alice Wielandner
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Cardiovascular and Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - Tim Wollenweber
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Chrysoula Vraka
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Verena Pichler
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Keziban Uyanik-Uenal
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Andreas Zuckermann
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Marcus Hacker
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Christian Loewe
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Cardiovascular and Interventional Radiology, Medical University of Vienna, Vienna, Austria
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18
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Elkaryoni A, Abu-Sheasha G, Altibi AM, Hassan A, Ellakany K, Nanda NC. Diagnostic accuracy of dobutamine stress echocardiography in the detection of cardiac allograft vasculopathy in heart transplant recipients: A systematic review and meta-analysis study. Echocardiography 2019; 36:528-536. [PMID: 30726558 DOI: 10.1111/echo.14268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 11/28/2018] [Accepted: 01/06/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Dobutamine stress echocardiography (DSE) is a well-established imaging modality used to screen patients with mild-to-moderate risk for coronary artery disease. In heart transplantation recipients, cardiac allograft vasculopathy (CAV) is a common and lethal complication. The use of DSE to detect CAV showed promising results initially, but later studies showed limitation in its use to detect CAV. It is unclear if this cohort of patients derives benefit from DSE. METHODS We searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and Scopus from inception through March 2018 for studies examining the accuracy of DSE in correlation to coronary angiography (CA) or intravascular ultrasound (IVUS) to detect CAV. Original studies comparing the ability of DSE to detect CAV in comparison with CA or IVUS were included. Relevant data were extracted and hierarchical summary receiver operating characteristic analysis was conducted to test the overall diagnostic accuracy of DSE for patients with CAV. RESULTS Eleven studies (749 participants) met the inclusion criteria. The sensitivity of DSE varied from 1.7% to 93.8%, and specificity, from 54.8% to 98.8%. Pooled sensitivity was 60.2% (95% confidence interval (CI), 33.0%-82.3%) and specificity 85.7% (95% CI, 73.8%-92.7%). DSE had an overall diagnostic odds ratio (OR) of 9.1 (95% CI, 4.6-17.8), positive likelihood ratio (LR+) of 4.1 (95% CI, 2.8-6.1), negative likelihood ratio (LR-) of 0.47 (95% CI: 0.23-0.73), and area under curve (AUC) of 0.73 (95% CI, 0.72-0.75). Heterogeneity among studies was not statistically significant (τ2 = 0.32, Cochran's Q = 9.5, P = 0.483). CONCLUSION Dobutamine stress echocardiography has a limited sensitivity to detect early CAV but its specificity is much higher. There remains a need for an alternative noninvasive modality which will have both high sensitivity and high specificity for detecting CAV.
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Affiliation(s)
- Ahmed Elkaryoni
- Division of Internal Medicine, University of Missouri Kansas City, Kansas City, Missouri
| | - Ghada Abu-Sheasha
- Division of Biomedical Statistics and Medical Informatics, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Ahmed M Altibi
- Division of Internal Medicine, Henry Ford Allegiance Health, Jackson, Michigan
| | - Adil Hassan
- Division of Internal Medicine, University of Missouri Kansas City, Kansas City, Missouri
| | - Karim Ellakany
- Division of Cardiovascular Disease, University of Alexandria School of medicine, Alexandria, Egypt
| | - Navin C Nanda
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
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19
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Mortality, Resource Utilization, and Inpatient Costs Vary Among Pediatric Heart Transplant Indications: A Merged Data Set Analysis From the United Network for Organ Sharing and Pediatric Health Information Systems Databases. J Card Fail 2019; 25:27-35. [DOI: 10.1016/j.cardfail.2018.11.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 11/09/2018] [Accepted: 11/20/2018] [Indexed: 11/22/2022]
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20
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Almufleh A, Garuba H, Mielniczuk LM, Davies RA, Stadnick E, Belanger E, Dick A, Kozuszko S, Ross HJ, Chih S. Diffuse Subepicardial Late Gadolinium Enhancement After Heart Transplant: A Potentially Ominous Finding. Can J Cardiol 2018; 34:1687.e3-1687.e7. [PMID: 30527162 DOI: 10.1016/j.cjca.2018.08.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 08/16/2018] [Accepted: 08/16/2018] [Indexed: 11/25/2022] Open
Abstract
Late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging has prognostic utility in populations with cardiac disease, including heart transplant (HT) recipients. The etiology of specific LGE patterns and their correlation with outcomes after HT are unclear. Antibody-mediated rejection and cardiac allograft vasculopathy are major causes of death, and their evaluation remains challenging. We report identical diffuse subepicardial LGE in 2 highly allosensitized HT recipients who developed allograft failure. We postulate this LGE pattern may be related to antibody-mediated rejection and cardiac allograft vasculopathy, and portends poor outcomes. These cases illustrate a potential role of cardiac magnetic resonance for antibody-mediated rejection evaluation and risk stratification.
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Affiliation(s)
- Aws Almufleh
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Cardiac Sciences Department, King Saud University, Riyadh, Saudi Arabia
| | - Habibat Garuba
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Lisa M Mielniczuk
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ross A Davies
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ellamae Stadnick
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Eric Belanger
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alexander Dick
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stella Kozuszko
- Peter Munk Cardiac Centre, Toronto General Hospital-University Health Network, Toronto, Ontario, Canada
| | - Heather J Ross
- Peter Munk Cardiac Centre, Toronto General Hospital-University Health Network, Toronto, Ontario, Canada
| | - Sharon Chih
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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21
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Narang A, Blair JE, Patel MB, Mor-Avi V, Fedson SE, Uriel N, Lang RM, Patel AR. Myocardial perfusion reserve and global longitudinal strain as potential markers of coronary allograft vasculopathy in late-stage orthotopic heart transplantation. Int J Cardiovasc Imaging 2018; 34:1607-1617. [PMID: 29728952 PMCID: PMC6160357 DOI: 10.1007/s10554-018-1364-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 04/29/2018] [Indexed: 12/30/2022]
Abstract
Coronary allograft vasculopathy (CAV) is a major cause of mortality in late-stage orthotopic heart transplantation (OHT) patients. Recent evidence has shown that myocardial perfusion reserve (MPR) derived from vasodilator cardiovascular magnetic resonance imaging (vCMR) and global longitudinal strain (GLS) from transthoracic echocardiography (TTE) are useful to detect CAV. However, previous studies have not comprehensively addressed whether these parameters are confounded by allograft rejection, myocardial scar/fibrosis, or allograft dysfunction. Our aim was to determine whether changes in late post-OHT MPR and GLS are due to CAV or other confounding factors. Twenty OHT patients (time from transplant to vCMR was 8.1 ± 4.1 years) and 30 controls (10 healthy volunteers and 20 with prior myocardial infarction to provide perspective with regards to the severity of any abnormalities seen in post-OHT patients) underwent vasodilator vCMR from which MPR index (MPRi), left ventricular ejection fraction (LVEF), and burden of late gadolinium enhancement (LGE) were quantified. TTE was used to measure GLS. The presence of CAV was determined from invasive coronary angiograms using thrombolysis in myocardial infarction (TIMI) frame counts and grading severity per guidelines. Previous endomyocardial biopsies were reviewed to assess association with episodes of rejection. We examined the correlations between MPRi and GLS with markers of CAV, allograft function, scar/fibrosis, and rejection. MPRi was abnormal in post-OHT patients compared to both healthy volunteers and MI controls. While there was no relationship between MPRi or GLS and LVEF, episodes of rejection, or LGE burden, both MPRi and GLS were associated with TIMI frame counts and presence and severity of CAV. Additionally, MPRi correlated with GLS (R = 0.68, P = 0.0002). In conclusion, MPRi and GLS are abnormal in late-stage OHT and associated with CAV, but not related to allograft rejection, myocardial scar/fibrosis, or allograft dysfunction. Non-invasive monitoring of MPRi and GLS may be a useful strategy to detect CAV.
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Affiliation(s)
- Akhil Narang
- Department of Medicine, University of Chicago Medicine, 5758 S. Maryland Avenue, MC9067, Chicago, IL, 60637, USA
| | - John E Blair
- Department of Medicine, University of Chicago Medicine, 5758 S. Maryland Avenue, MC9067, Chicago, IL, 60637, USA
| | - Mita B Patel
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Victor Mor-Avi
- Department of Medicine, University of Chicago Medicine, 5758 S. Maryland Avenue, MC9067, Chicago, IL, 60637, USA
| | - Savitri E Fedson
- Center for Medical Ethics and Health Policy, Baylor School of Medicine, Houston, TX, USA
| | - Nir Uriel
- Department of Medicine, University of Chicago Medicine, 5758 S. Maryland Avenue, MC9067, Chicago, IL, 60637, USA
| | - Roberto M Lang
- Department of Medicine, University of Chicago Medicine, 5758 S. Maryland Avenue, MC9067, Chicago, IL, 60637, USA
- Department of Radiology, University of Chicago, Chicago, IL, USA
| | - Amit R Patel
- Department of Medicine, University of Chicago Medicine, 5758 S. Maryland Avenue, MC9067, Chicago, IL, 60637, USA.
- Department of Radiology, University of Chicago, Chicago, IL, USA.
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22
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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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23
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Pedrotti P, Vittori C, Facchetti R, Pedretti S, Dellegrottaglie S, Milazzo A, Frigerio M, Cipriani M, Giannattasio C, Roghi A, Rimoldi O. Prognostic impact of late gadolinium enhancement in the risk stratification of heart transplant patients. Eur Heart J Cardiovasc Imaging 2016; 18:130-137. [DOI: 10.1093/ehjci/jew186] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 08/11/2016] [Indexed: 11/15/2022] Open
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McDiarmid AK, Plein S, Ross HJ. Emerging imaging techniques after cardiac transplantation. J Heart Lung Transplant 2016; 35:1399-1411. [PMID: 27523792 DOI: 10.1016/j.healun.2016.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/13/2016] [Accepted: 06/22/2016] [Indexed: 10/21/2022] Open
Abstract
Improvements in survival after cardiac transplantation have in part been driven by improved graft surveillance. Graft surveillance relies mainly on 3 techniques: coronary angiography, endomyocardial biopsy and echocardiography. Developments in invasive and non-invasive imaging technology have revolutionized assessment of the heart in both health and disease, offering new insights into tissue composition and myocardial metabolism. Herein we aim to review the strengths and weaknesses of these techniques, and summarize the evidence in the following 5 fields of cardiac imaging after transplantation: cardiovascular magnetic resonance; computed tomography; positron emission tomography; single-photon emission computed tomography; and optical coherence tomography and molecular imaging techniques.
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Affiliation(s)
- Adam K McDiarmid
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada; Multidisciplinary Cardiovascular Research Centre and Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre and Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Heather J Ross
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
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25
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Myocardial tissue remodeling after orthotopic heart transplantation: a pilot cardiac magnetic resonance study. Int J Cardiovasc Imaging 2016; 34:15-24. [DOI: 10.1007/s10554-016-0937-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 07/08/2016] [Indexed: 01/09/2023]
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27
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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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