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Clinical Utility of SPECT in the Heart Transplant Population: Analysis From a Single Large-volume Center. Transplantation 2022; 106:623-632. [PMID: 33901107 PMCID: PMC8528902 DOI: 10.1097/tp.0000000000003791] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Survival after heart transplant has greatly improved, with median survival now over 12 years. Cardiac allograft vasculopathy (CAV) has become a major source of long-term morbidity and mortality. Single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) is used for CAV surveillance, but there is limited data on its prognostic utility. METHODS We retrospectively identified patients undergoing SPECT MPI for CAV surveillance at a single, large-volume center. Images were assessed with semiquantitative visual scoring (summed stress score [SSS] and summed rest score) and quantitatively with total perfusion defect (TPD). RESULTS We studied 503 patients (mean age 62.5, 69.3% male) at a median of 9.0 years post-transplant. During mean follow-up of 5.1 ± 2.5 years, 114 (22.6%) patients died. The diagnostic accuracy for significant CAV (ISHLT grade 2 or 3) was highest for SSS with an area under the curve of 0.650 and stress TPD (area under the curve, 0.648), with no significant difference between SSS and stress TPD (P = 0.061). Stress TPD (adjusted hazard ratio, 1.07; P = 0.018) was independently associated with all-cause mortality, while SSS was not (P = 0.064). The prognostic accuracy of quantitative assessment of perfusion tended to be higher compared with semiquantitative assessment, with the highest accuracy for stress TPD (area under the receiver operating curve 0.584). CONCLUSIONS While SPECT MPI identified a cohort of higher risk patients, with quantitative analysis of perfusion demonstrating higher prognostic accuracy. However, the overall prognostic accuracy was modest and alternative noninvasive modalities may be more suitable for CAV surveillance.
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Sciaccaluga C, Ghionzoli N, Mandoli GE, Sisti N, D'Ascenzi F, Focardi M, Bernazzali S, Vergaro G, Emdin M, Valente S, Cameli M. The role of non-invasive imaging modalities in cardiac allograft vasculopathy: an updated focus on current evidences. Heart Fail Rev 2021; 27:1235-1246. [PMID: 34383194 PMCID: PMC9197817 DOI: 10.1007/s10741-021-10155-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 11/24/2022]
Abstract
Cardiac allograft vasculopathy (CAV) is an obliterative and diffuse form of vasculopathy affecting almost 50% of patients after 10 years from heart transplant and represents the most common cause of long-term cardiovascular mortality among heart transplant recipients. The gold standard diagnostic technique is still invasive coronary angiography, which however holds potential for complications, especially contrast-related kidney injury and procedure-related vascular lesions. Non-invasive and contrast-sparing imaging techniques have been advocated and investigated over the past decades, in order to identify those that could replace coronary angiography or at least reach comparable accuracy in CAV detection. In addition, they could help the clinician in defining optimal timing for invasive testing. This review attempts to examine the currently available non-invasive imaging techniques that may be used in the follow-up of heart transplant patients, spanning from echocardiography to nuclear imaging, cardiac magnetic resonance and cardiac computed tomography angiography, weighting their advantages and disadvantages.
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Affiliation(s)
- C Sciaccaluga
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy.
| | - N Ghionzoli
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - G E Mandoli
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - N Sisti
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - F D'Ascenzi
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - M Focardi
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - S Bernazzali
- Department of Cardiac Surgery, University Hospital of Siena, Siena, Italy
| | - G Vergaro
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - M Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - S Valente
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - M Cameli
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
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Veenis JF, Boiten HJ, van den Berge JC, Caliskan K, Maat APWM, Valkema R, Constantinescu AA, Manintveld OC, Zijlstra F, van Domburg RT, Schinkel AFL. Prediction of long-term (> 10 year) cardiovascular outcomes in heart transplant recipients: Value of stress technetium-99m tetrofosmin myocardial perfusion imaging. J Nucl Cardiol 2019; 26:845-852. [PMID: 29116562 DOI: 10.1007/s12350-017-1089-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 09/18/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Myocardial perfusion imaging (MPI) using single-photon emission computed tomography (SPECT) is useful in the evaluation of cardiac allograft vasculopathy (CAV) in heart transplant (HTx) recipients. The current study evaluated the long-term prognostic value of stress SPECT MPI for predicting all-cause mortality and cardiac events in HTx recipients. METHODS The study population consisted of 166 HTx recipients (mean age 54 ± 10 years, 84% male) who underwent exercise or dobutamine stress 99mTc-tetrofosmin SPECT MPI for the assessment of CAV. An abnormal SPECT MPI was defined as the presence of a fixed or a reversible perfusion defect. Endpoints were all-cause mortality, cardiac mortality, and non-fatal myocardial infarction (MI). RESULTS MPI abnormalities were detected in 55 patients (33%), including fixed defects in 28 patients (17%), partially reversible in 17 patients (10%), and completely reversible defects in 10 patients (6%). During a median follow-up of 12.8 years (range 0-15, mean follow-up 9.5 years), 109 (66%) patients died (all-cause mortality), of which 67 (40%) were due to cardiac causes. A total of 5 (3%) patients experienced a non-fatal MI. HTx recipients with a normal stress 99mTc-tetrofosmin SPECT MPI had a significantly better prognosis as compared with those with an abnormal study, up to 5 years after the initial test. The presence of a reversible perfusion defect was a significant predictor of all-cause mortality, cardiac mortality, and major cardiac events, during the entire follow-up period. CONCLUSIONS Stress 99mTc-tetrofosmin SPECT MPI provides valuable prognostic information for the prediction of long-term outcome in HTx recipients. Patients with a normal stress 99mTc-tetrofosmin SPECT MPI have a significantly better prognosis as compared with those with an abnormal study, up to 5 years after initial testing.
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Affiliation(s)
- Jesse F Veenis
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Hendrik J Boiten
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands.
- Department of Cardiology, Thoraxcenter, Erasmus MC, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
| | - Jan C van den Berge
- Department of Cardiology, Thoraxcenter, Erasmus MC, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Alex P W M Maat
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Roelf Valkema
- Department of Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Felix Zijlstra
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ron T van Domburg
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Arend F L Schinkel
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
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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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Abstract
PURPOSE OF REVIEW Cardiac allograft vasculopathy (CAV) is a major limitation to long-term survival after heart transplantation. Innovative new techniques to diagnose CAV have been applied to detect disease. This review will examine the current diagnostic and treatment options available to clinicians for CAV. RECENT FINDINGS Diagnostic modalities addressing the pathophysiology underlying CAV (arterial wall thickening and decreased coronary blood flow) improve diagnostic sensitivity when compared to traditional (angiography and dobutamine stress echocardiography) techniques. SUMMARY Limited options are available to prevent and treat CAV; however, progress has been made in making an earlier and more accurate diagnosis. Future research is needed to identify the optimal time to modify immunosuppression and investigate novel treatments for CAV.
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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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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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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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10
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Badano LP, Miglioranza MH, Edvardsen T, Colafranceschi AS, Muraru D, Bacal F, Nieman K, Zoppellaro G, Marcondes Braga FG, Binder T, Habib G, Lancellotti P, Sicari R, Cosyns B, Donal E, Lombardi M, Sarvari S. European Association of Cardiovascular Imaging/Cardiovascular Imaging Department of the Brazilian Society of Cardiology recommendations for the use of cardiac imaging to assess and follow patients after heart transplantation. ACTA ACUST UNITED AC 2015; 16:919-48. [DOI: 10.1093/ehjci/jev139] [Citation(s) in RCA: 141] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/02/2015] [Indexed: 01/10/2023]
Affiliation(s)
- Luigi P. Badano
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, School of Medicine, Via Giustiniani 2, 35128 Padova, Italy
| | | | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | | | - Denisa Muraru
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, School of Medicine, Via Giustiniani 2, 35128 Padova, Italy
| | - Fernando Bacal
- Heart Transplant Department, Heart Institute, University of São Paulo, São Paulo, Brazil
| | - Koen Nieman
- Intensive Cardiac Care Unit and Cardiac CT Research, Erasmus MC, Rotterdam, The Netherlands
| | - Giacomo Zoppellaro
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, School of Medicine, Via Giustiniani 2, 35128 Padova, Italy
| | | | - Thomas Binder
- Department of Cardiology, University of Vienna, Wien, Austria
| | - Gilbert Habib
- Service de Cardiologie, Hôpital La Timone, Marseille, France
| | - Patrizio Lancellotti
- Department of Cardiology, Heart Valve Clinic, University of Liège, GIGA Cardiovascular Sciences, CHU Sart Tilman, Liège, Belgium
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12
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Pollack A, Nazif T, Mancini D, Weisz G. Detection and Imaging of Cardiac Allograft Vasculopathy. JACC Cardiovasc Imaging 2013; 6:613-23. [DOI: 10.1016/j.jcmg.2013.03.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 03/18/2013] [Accepted: 03/21/2013] [Indexed: 10/26/2022]
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13
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Graute V, Jansen N, Sohn HY, Becker A, Klein B, Schmid I, Greil S, Lehner S, Bartenstein P, Pfluger T, Hacker M. Diagnostic role of whole-body [18F]-FDG positron emission tomography in patients with symptoms suspicious for malignancy after heart transplantation. J Heart Lung Transplant 2012; 31:958-66. [DOI: 10.1016/j.healun.2012.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 05/15/2012] [Accepted: 05/15/2012] [Indexed: 10/28/2022] Open
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Wenning C, Stypmann J, Papavassilis P, Sindermann J, Schober O, Hoffmeier A, Scheld HH, Stegger L, Schäfers M. Left ventricular dilation and functional impairment assessed by gated SPECT are indicators of cardiac allograft vasculopathy in heart transplant recipients. J Heart Lung Transplant 2012; 31:719-28. [DOI: 10.1016/j.healun.2012.02.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Revised: 01/31/2012] [Accepted: 02/11/2012] [Indexed: 11/29/2022] Open
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Miller CA, Chowdhary S, Ray SG, Sarma J, Williams SG, Yonan N, Mittal TK, Schmitt M. Role of Noninvasive Imaging in the Diagnosis of Cardiac Allograft Vasculopathy. Circ Cardiovasc Imaging 2011; 4:583-93. [PMID: 21934085 DOI: 10.1161/circimaging.110.961425] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Christopher A. Miller
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Saqib Chowdhary
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Simon G. Ray
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Jaydeep Sarma
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Simon G. Williams
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Nizar Yonan
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Tarun K. Mittal
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Matthias Schmitt
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
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Colvin-Adams M, Agnihotri A. Cardiac allograft vasculopathy: current knowledge and future direction. Clin Transplant 2011; 25:175-84. [PMID: 21457328 DOI: 10.1111/j.1399-0012.2010.01307.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Cardiac allograft vasculopathy (CAV) is a unique form of coronary artery disease affecting heart transplant recipients. Although prognosis of heart transplant recipients has improved over time, CAV remains a significant cause of mortality beyond the first year of cardiac transplantation. Many traditional and non-traditional risk factors for the development of CAV have been described. Traditional risk factors include dyslipidemia, diabetes and hypertension. Non-traditional risk factors include cytomegalovirus infection, HLA mismatch, antibody-mediated rejection, and mode of donor brain death. There is a complex interplay between immunological and non-immunological factors ultimately leading to endothelial injury and exaggerated repair response. Pathologically, CAV manifests as fibroelastic proliferation of intima and luminal stenosis. Early diagnosis is paramount as heart transplant recipients are frequently asymptomatic owing to cardiac denervation related to the transplant surgery. Intravascular ultrasound (IVUS) offers many advantages over conventional angiography and is an excellent predictor of prognosis in heart transplant recipients. Many non-invasive diagnostic tests including dobutamine stress echocardiography, CT angiography, and MRI are available; though, none has replaced angiography. This review discusses the risk factors, pathogenesis, and diagnosis of CAV and highlights some current concepts and recent developments in this field.
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Abstract
Cardiac allograft vasculopathy (CAV), characterized by diffuse intimal thickening and luminal narrowing in the arteries of the allograft, is the leading cause of morbidity and mortality in cardiac transplant recipients. Many transplant centers perform routine annual surveillance coronary angiography. However, angiography can underdiagnose or miss CAV due to its diffuse nature. Intravascular ultrasound (IVUS) is more sensitive than angiography. IVUS provides not only accurate information on lumen size, but also quantification of intimal thickening, vessel wall morphology, and composition. IVUS has evolved as a valuable adjunct to angiography and the optimal diagnostic tool for early detection. Noninvasive testing such as dobutamine stress echocardiography and nuclear stress test have shown considerable accuracy in diagnosing significant CAV. Computed tomographic imaging and cardiac magnetic resonance imaging are promising new modalities but require further study. This article reviews the diagnostic methods that are currently available.
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Manrique A, Bernard M, Hitzel A, Bubenheim M, Tron C, Agostini D, Cribier A, Véra P, Bessou JP, Redonnet M. Diagnostic and prognostic value of myocardial perfusion gated SPECT in orthotopic heart transplant recipients. J Nucl Cardiol 2010; 17:197-206. [PMID: 20151240 DOI: 10.1007/s12350-009-9166-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Accepted: 11/03/2009] [Indexed: 12/30/2022]
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) limits long-term survival after heart transplantation. Diagnostic and prognostic value of gated single photon emission computed tomography (gated SPECT) has not been documented in this setting. METHODS AND RESULTS We identified 110 consecutive heart transplant recipients (with transplantation >18 months) who underwent stress-rest gated SPECT and coronary angiography within 1 month, and were clinically monitored in a single heart transplantation center. Visual scoring of perfusion and wall motion images used a 16-segment model. Left ventricular function was automatically calculated. Coronary angiography was normal in 64 patients (58%) and abnormal in 46 (any CAV, 42%), of whom 19 had severe stenoses. Sensitivity and negative predictive (NPV) value were .63 and .75 for identification of any CAV, and .84 and .96 for severe CAV. Cox regression analysis showed that independent predictors of cardiac death and retransplantation were the presence of any angiographic CAV lesions (RR = 8.816, P = .043) and a stress perfusion defect >3 segments (RR = 5.607, P = .0053). A stress perfusion defect >3 segments predicted the need for late coronary revascularization >2 months (RR = 6.11, P = .0002). CONCLUSIONS We conclude that perfusion gated SPECT is a useful noninvasive screening test and may be proposed to help identify heart transplant recipients with a high risk of poor clinical outcome. A normal gated SPECT was associated with a low risk of cardiac hard event and might alleviate the need for coronary angiography.
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Affiliation(s)
- Alain Manrique
- Department of Nuclear Medicine, Rouen University Hospital, Henri Becquerel Center, Rouen, France.
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Estep JD, Shah DJ, Nagueh SF, Mahmarian JJ, Torre-Amione G, Zoghbi WA. The role of multimodality cardiac imaging in the transplanted heart. JACC Cardiovasc Imaging 2009; 2:1126-40. [PMID: 19761994 DOI: 10.1016/j.jcmg.2009.06.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Revised: 06/19/2009] [Accepted: 06/24/2009] [Indexed: 10/20/2022]
Abstract
Heart transplantation (HT) is an established life-saving treatment option for patients with end-stage heart failure. Despite many advances in the field, the development of acute cellular rejection (ACR) and cardiac allograft vasculopathy (CAV) represent significant causes of 1- and 5-year morbidity and mortality, respectively. The search for noninvasive techniques to assess cardiac allograft function and detect treatable ACR and CAV remains a priority objective for heart transplant professionals. In this review we will: 1) highlight the clinical significance of ACR and CAV in adult cardiac transplant recipients and 2) discuss how different noninvasive imaging modalities (echocardiography, cardiac computed tomography, myocardial perfusion imaging, and cardiac magnetic resonance) have been used in the evaluation of these clinical challenges after HT.
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Affiliation(s)
- Jerry D Estep
- Department of Cardiology, Section of Heart Failure and Heart Transplantation, and Cardiovascular Imaging Institute, Methodist DeBakey Heart and Vascular Center, Houston, Texas 77030, USA.
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Tc-99m sestamibi single photon emission computed tomography for guiding percutaneous coronary intervention in patients with multivessel disease: a comparison with quantitative coronary angiography and fractional flow reserve. Int J Cardiovasc Imaging 2009; 26:203-13. [PMID: 19760091 DOI: 10.1007/s10554-009-9510-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Accepted: 09/01/2009] [Indexed: 01/17/2023]
Abstract
To evaluate the accuracy of myocardial perfusion SPECT (MPI) in the detection and allocation of vessel specific perfusion defects (PD) using standard distribution territories in a routine clinical procedure of patients with multivessel disease (MVD). Combined quantitative coronary angiography and fractional flow reserve (QCA/FFR) measurements were used as invasive reference standard. 216 vessels in 72 MVD patients (67 +/- 10 years, 28 female) were investigated using MPI and QCA. FFR of 93 vessels with intermediate stenoses was determined. MPI detected significant stenoses according to QCA/FFR findings with a sensitivity of 85%. However, vessel-based evaluation using standard myocardial distribution territories delivered a sensitivity of only 62% (28 MPI+ out of 45 (QCA/FFR)+ findings), with specificity, PPV and NPV of 90, 62 and 90%. 7/17 false positive and 7/17 false negative findings (41%) could be attributed to incorrect allocation of reversible PD to their respective coronary arteries. 6/17 (35%) perfusion territories were classified as false negative when additional fixed PD were present. MPI had reasonable sensitivity for the detection of significant coronary artery disease in patients with multivessel disease. However, sensitivity decreased markedly, when the significance of each individual stenosis was evaluated using standard myocardial supplying territories. In this setting, 41% of false negative and false positive MPI findings resulted from incorrect allocation of reversible perfusion defects to their determining supplying vessel.
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Abstract
PURPOSE OF REVIEW Graft coronary artery disease is the leading cardiac cause of death in patients who have undergone cardiac transplantation. Due to denervation, classic symptoms of angina are not reliable. Many transplant centers have a protocol of routine annual surveillance cardiac angiography because treatment options are limited, especially with advanced disease. Angiography is an assessment of the arterial lumen, however, and can miss nonfocal disease. This paper reviews invasive and noninvasive diagnostic tools for graft coronary artery disease. Intravascular ultrasound is the most sensitive, but the cost and lack of widespread expertise make it unpopular. Noninvasive techniques have been studied. An ideal test would be sufficiently sensitive to detect disease and allow for prognostic information. Dobutamine echocardiography is the most sensitive noninvasive test but can have a high false-positive rate. It is also not universally available. Exercise nuclear imaging is specific and can be used as a confirmatory test in patients with positive dobutamine echocardiograms. RECENT FINDINGS Computed tomographic imaging and cardiac magnetic resonance imaging are exciting new modalities but require further study. SUMMARY There is no test sensitive and specific enough yet that can be confidently used to replace coronary angiography.
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Affiliation(s)
- Malek Kass
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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22
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Cardiac Allograft Vasculopathy: Differences in De Novo and Maintenance Heart Transplant Recipients. Transplantation 2006. [DOI: 10.1097/01.tp.0000243150.89762.fc] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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