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Kuczaj A, Pawlak S, Głowacki J, Antończyk R, Śliwka J, Przybyłowski P, Hrapkowicz T. Utility of 64-Slice Coronary Computed Tomography Angiography in Heart Transplant Recipients. Transplant Proc 2024; 56:836-840. [PMID: 38729834 DOI: 10.1016/j.transproceed.2024.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 03/29/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Graft vasculopathy is a leading cause of death after heart transplantation (HTx). Diagnosing cardiac allograft vasculopathy (CAV) within this patient group poses significant challenges. This study aimed to evaluate the safety and efficacy of coronary computed tomographic angiography (CCTA) in patients after HTx. METHODS We enrolled 107 consecutive HTx recipients (26 women, mean age 50 ± 17 years); all were ≥3 years post-HTx with minimal or no evidence of CAV in a prior coronary angiography performed a minimum of 2 years before the current examination. The inclusion criteria comprised an estimated glomerular filtration rate (eGFR) of ≥30, absence of new heart failure symptoms, and no contraindications to iodine contrast or CT scans. All patients underwent a 64-slice CCTA. In cases of minimal or no changes, noninvasive follow-up examinations were conducted. Significant changes in CT prompted additional coronary angiography. RESULTS Of the enrolled participants, 9 exhibited minimal changes; 98 displayed no changes in coronary angiography. The median time since transplant was 7 years, with IQR of 4 to 11.25 years. Significant changes were excluded in 98 patients. Among the 9 patients with suspected significant CAV, significant changes were confirmed in 8 patients, resulting in percutaneous transluminal coronary angioplasty (PTCA) performed in 6. One patient from this group died shortly after PTCA. No cardiovascular incidents were observed within the remaining group. The median follow-up period was 539 (IQR = 289-654 days). The mean left ventricular ejection fraction at follow-up was 58% ± 5% compared with 58% ± 4% at baseline. At follow-up, the mean eGFR was 64 ± 18 mL/kg/1.73 m2 compared with the baseline value of 67.2 mL/kg/1.73 m2. CONCLUSIONS CCTA appears to offer a secure and efficient means of assessment in HTx recipients.
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Affiliation(s)
- Agnieszka Kuczaj
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland; Silesian Center for Heart Diseases, Zabrze, Poland.
| | - Szymon Pawlak
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland; Silesian Center for Heart Diseases, Zabrze, Poland
| | - Jan Głowacki
- Silesian Center for Heart Diseases, Zabrze, Poland; Department of Radiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Remigiusz Antończyk
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland; Silesian Center for Heart Diseases, Zabrze, Poland
| | - Joanna Śliwka
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland; Silesian Center for Heart Diseases, Zabrze, Poland
| | - Piotr Przybyłowski
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland; Silesian Center for Heart Diseases, Zabrze, Poland
| | - Tomasz Hrapkowicz
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland; Silesian Center for Heart Diseases, Zabrze, Poland
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2
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Kadosh BS, Birs AS, Flattery E, Stachel M, Hong KN, Xia Y, Gidea C, Aslam S, Razzouk L, Saraon T, Goldberg R, Rao S, Pretorius V, Moazami N, Smith DE, Adler ED, Reyentovich A. Cardiac allograft vasculopathy in heart transplant recipients from hepatitis C viremic donors. Clin Transplant 2024; 38:e15294. [PMID: 38545881 DOI: 10.1111/ctr.15294] [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: 02/19/2023] [Revised: 02/19/2024] [Accepted: 03/08/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Recent studies suggest the transplantation of Hepatitis C (HCV) hearts from viremic donors is associated with comparable 1 year survival to nonviremic donors. Though HCV viremia is a known risk factor for accelerated atherosclerosis, data on cardiac allograft vasculopathy (CAV) outcomes are limited. We compared the incidence of CAV in heart transplant recipients from HCV viremic donors (nucleic acid amplification test positive; NAT+) compared to non-HCV infected donors (NAT-). METHODS We retrospectively reviewed annual coronary angiograms with intravascular ultrasound from April 2017 to August 2020 at two large cardiac transplant centers. CAV was graded according to ISHLT guidelines. Maximal intimal thickness (MIT) ≥ 0.5 mm was considered significant for subclinical disease. RESULTS Among 270 heart transplant recipients (mean age 54; 77% male), 62 patients were transplanted from NAT+ donors. CAV ≥ grade 1 was present in 8.8% of the NAT+ versus 16.8% of the NAT- group at 1 year, 20% versus 28.8% at 2 years, and 33.3% versus 41.5% at 3 years. After adjusting for donor age, donor smoking history, recipient BMI, recipient, hypertension, and recipient diabetes, NAT+ status did not confer increased risk of CAV (HR.80; 95% CI.45-1.40, p = 0.43) or subclinical IVUS disease (HR.87; 95% CI.58-1.30, p = 0.49). Additionally, there was no difference in the presence of rapidly progressive lesions on IVUS. CONCLUSION Our data show that NAT+ donors conferred no increased risk for early CAV or subclinical IVUS disease following transplantation in a cohort of heart transplant patients who were treated for HCV, suggesting the short-term safety of this strategy to maximize the pool of available donor hearts.
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Affiliation(s)
- Bernard S Kadosh
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Antoinette S Birs
- Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Erin Flattery
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Maxine Stachel
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Kimberly N Hong
- Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Yuhe Xia
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Claudia Gidea
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Saima Aslam
- Division of Infectious Disease, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Louai Razzouk
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Tajinderpal Saraon
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Randal Goldberg
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Shaline Rao
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Victor Pretorius
- Department of Cardiothoracic Surgery, University of California San Diego, La Jolla, California, USA
| | - Nader Moazami
- Department of Cardiothoracic Surgery, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Deane E Smith
- Department of Cardiothoracic Surgery, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Eric D Adler
- Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Alex Reyentovich
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, New York, USA
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3
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Shah H, Lee I, Rao S, Suddath W, Rodrigo M, Mohammed S, Molina E, García-Garcia HM, Kenigsberg BB. Quantitative flow ratio computed from invasive coronary angiography as a predictor for cardiac allograft vasculopathy after cardiac transplant. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:451-458. [PMID: 38117378 DOI: 10.1007/s10554-023-03012-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023]
Abstract
Cardiac allograft vasculopathy (CAV) is a significant determinant of long-term survival in heart transplant recipients. Standard CAV screening typically utilizes invasive coronary angiography (ICA). Quantitative flow ratio (QFR) is a computational method for functional testing of coronary stenosis, and may add diagnostic value to ICA in assessing CAV. Consecutive subjects who received heart transplantation and underwent two separate routine coronary angiograms between January 2013 and April 2016 were enrolled. Coronary angiograms and IVUS were performed per local protocol at 1, 2, 3 and 5 years post-transplant. QFR was calculated offline. CAV was assessed semi-quantitively based on coronary angiogram results. Twenty-two patients were enrolled. Mean time from transplant to first included ICA was 2.1 years. QFR in at least 1 coronary vessel was interpretable in 19/22 (86%) of initial ICA (QFR1). QFR1 correlated well with the CAV score derived from the second ICA (CAV2) with a clustering of CAV at lower QFR values. In a receiver-operating characteristic (ROC) analysis, an optimal QFR threshold of 0.88 yielded 0.94 sensitivity and 0.67 specificity (AUC of 0.79) for at least non-obstructive subsequent CAV. Initial angiographically and intravascular ultrasound derived CAV severity poorly predicted subsequent CAV severity. QFR derived from invasive coronary angiography predicts subsequent development of CAV more accurately than angiography and intravascular ultrasound. This novel method of coronary flow assessment in recipients of heart transplantation may be useful to diagnose and predict subsequent CAV development.
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Affiliation(s)
- Harsh Shah
- Department of Cardiology, Jefferson Einstein Hospital, Philadelphia, PA, USA
| | - Injoon Lee
- Department of Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Sriram Rao
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - William Suddath
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Maria Rodrigo
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Selma Mohammed
- Department of Cardiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Ezequiel Molina
- Department of Cardiac Surgery, Piedmont Heart Institute, Atlanta, GA, USA
| | - Hector M García-Garcia
- MedStar Cardiovascular Research Network, MedStar Washington Hospital Center, Washington, DC, USA
| | - Benjamin B Kenigsberg
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA.
- Department of Critical Care, MedStar Washington Hospital Center, 110 Irving St., NW, Rm A121, Washington, DC, 20010, USA.
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4
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Bora N, Balogh O, Ferenci T, Piroth Z. Functional Assessment of Long-Term Microvascular Cardiac Allograft Vasculopathy. J Pers Med 2023; 13:1686. [PMID: 38138913 PMCID: PMC10744790 DOI: 10.3390/jpm13121686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/20/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is a leading cause of death and retransplantation following heart transplantation (HTX). Surveillance angiography performed yearly is indicated for the early detection of the disease, but it remains of limited sensitivity. METHODS We performed bolus thermodilution-based coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) and fractional flow reserve (FFR) measurements in HTX patients undergoing yearly surveillance coronary angiography without overt CAV. RESULTS In total, 27 HTX patients were included who had 52 CFR, IMR, and FFR measurements at a mean of 43 months after HTX. Only five measurements were performed in the first year. CFR decreased significantly by 0.13 every year (p = 0.04) and IMR tended to increase by 0.98 every year (p = 0.051), whereas FFR did not change (p = 0.161) and remained well above 0.80 over time. After one year, CFR decreased significantly (p = 0.022) and IMR increased significantly (p = 0.015), whereas FFR remained unchanged (p = 0.72). CONCLUSIONS The functional status of the epicardial coronary arteries of transplanted hearts did not deteriorate over time. On the contrary, a significant decrease in CFR was noted. In view of the increasing IMR, this is caused by the deterioration of the function of microvasculature. CFR and IMR measurements may provide an early opportunity to diagnose CAV.
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Affiliation(s)
- Noemi Bora
- Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary; (N.B.); (O.B.)
- Károly Rácz Doctoral School of Clinical Medicine, Semmelweis University, 1085 Budapest, Hungary
| | - Orsolya Balogh
- Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary; (N.B.); (O.B.)
| | - Tamás Ferenci
- Physiological Controls Group, John von Neumann Faculty of Informatics, Obuda University, 1034 Budapest, Hungary;
| | - Zsolt Piroth
- Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary; (N.B.); (O.B.)
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5
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Marco I, López-Azor García JC, González Martín J, Severo Sánchez A, García-Cosío Carmena MD, Mancebo Sierra E, de Juan Bagudá J, Castrodeza Calvo J, Hernández Pérez FJ, Delgado JF. De Novo Donor-Specific Antibodies after Heart Transplantation: A Comprehensive Guide for Clinicians. J Clin Med 2023; 12:7474. [PMID: 38068526 PMCID: PMC10707043 DOI: 10.3390/jcm12237474] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 04/12/2024] Open
Abstract
Antibodies directed against donor-specific human leukocyte antigens (HLAs) can be detected de novo after heart transplantation and play a key role in long-term survival. De novo donor-specific antibodies (dnDSAs) have been associated with cardiac allograft vasculopathy, antibody-mediated rejection, and mortality. Advances in detection methods and international guideline recommendations have encouraged the adoption of screening protocols among heart transplant units. However, there is still a lack of consensus about the correct course of action after dnDSA detection. Treatment is usually started when antibody-mediated rejection is present; however, some dnDSAs appear years before graft failure is detected, and at this point, damage may be irreversible. In particular, class II, anti-HLA-DQ, complement binding, and persistent dnDSAs have been associated with worse outcomes. Growing evidence points towards a more aggressive management of dnDSA. For that purpose, better diagnostic tools are needed in order to identify subclinical graft injury. Cardiac magnetic resonance, strain techniques, or coronary physiology parameters could provide valuable information to identify patients at risk. Treatment of dnDSA usually involves plasmapheresis, intravenous immunoglobulin, immunoadsorption, and ritxumab, but the benefit of these therapies is still controversial. Future efforts should focus on establishing effective treatment protocols in order to improve long-term survival of heart transplant recipients.
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Affiliation(s)
- Irene Marco
- Cardiology Department, Hospital Universitario La Paz, 28046 Madrid, Spain;
| | - Juan Carlos López-Azor García
- Cardiology Department, Hospital Universitario Puerta de Hierro, 28222 Madrid, Spain; (J.C.L.-A.G.); (F.J.H.P.)
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- School of Medicine, Universidad Europea de Madrid, 28670 Madrid, Spain
| | - Javier González Martín
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Andrea Severo Sánchez
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - María Dolores García-Cosío Carmena
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Esther Mancebo Sierra
- Immunology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Javier de Juan Bagudá
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- School of Medicine, Universidad Europea de Madrid, 28670 Madrid, Spain
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Javier Castrodeza Calvo
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario Gregorio Marañón, 28007 Madrid, Spain
| | | | - Juan Francisco Delgado
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
- School of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
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6
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Koo BK, Hwang D, Park S, Kuramitsu S, Yonetsu T, Kim CH, Zhang J, Yang S, Doh JH, Jeong YH, Choi KH, Lee JM, Ahn JM, Matsuo H, Shin ES, Hu X, Low AF, Kubo T, Nam CW, Yong AS, Harding SA, Xu B, Hur SH, Choo GH, Tan HC, Mullasari A, Hsieh IC, Kakuta T, Akasaka T, Wang J, Tahk SJ, Fearon WF, Escaned J, Park SJ. Practical Application of Coronary Physiologic Assessment: Asia-Pacific Expert Consensus Document: Part 2. JACC. ASIA 2023; 3:825-842. [PMID: 38155788 PMCID: PMC10751650 DOI: 10.1016/j.jacasi.2023.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/08/2023] [Indexed: 12/30/2023]
Abstract
Coronary physiologic assessment is performed to measure coronary pressure, flow, and resistance or their surrogates to enable the selection of appropriate management strategy and its optimization for patients with coronary artery disease. The value of physiologic assessment is supported by a large body of clinical data that has led to major recommendations in all practice guidelines. This expert consensus document aims to convey practical and balanced recommendations and future perspectives for coronary physiologic assessment for physicians and patients in the Asia-Pacific region, based on updated information in the field that includes both wire- and image-based physiologic assessment. This is Part 2 of the whole consensus document, which provides theoretical and practical information on physiologic indexes for specific clinical conditions and patient statuses.
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Affiliation(s)
- Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Sungjoon Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Shoichi Kuramitsu
- Department of Cardiovascular Medicine, Sapporo Heart Center, Sapporo Cardio Vascular Clinic, Sapporo, Japan
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Chee Hae Kim
- Department of Internal Medicine and Cardiovascular Center, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jinlong Zhang
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Seokhun Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea and Department of Internal Medicine, Chung-Ang University School of Medicine, Seoul, Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Min Ahn
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Japan
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Xinyang Hu
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Adrian F. Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; National University Heart Centre, National University Health System, Singapore
| | - Takashi Kubo
- Department of Cardiology, Tokyo Medical University, Hachioji Medical Center, Tokyo, Japan
| | - Chang-Wook Nam
- Department of Internal Medicine and Cardiovascular Research Institute, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Andy S.C. Yong
- Department of Cardiology, Concord Hospital, University of Sydney, Sydney, Australia
| | - Scott A. Harding
- Department of Cardiology, Wellington Hospital, Wellington, New Zealand
| | - Bo Xu
- Department of Cardiology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Seung-Ho Hur
- Department of Internal Medicine and Cardiovascular Research Institute, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Gim Hooi Choo
- Department of Cardiology, Cardiac Vascular Sentral KL (CVSKL), Kuala Lumpur, Malaysia
| | - Huay Cheem Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; National University Heart Centre, National University Health System, Singapore
| | - Ajit Mullasari
- Department of Cardiology, Madras Medical Mission, Chennai, India
| | - I-Chang Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Jian'an Wang
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Seung-Jea Tahk
- Department of Cardiology, Ajou University Medical Center, Suwon, Korea
| | - William F. Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
| | - Seung-Jung Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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7
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Samuels BA, Shah SM, Widmer RJ, Kobayashi Y, Miner SES, Taqueti VR, Jeremias A, Albadri A, Blair JA, Kearney KE, Wei J, Park K, Barseghian El-Farra A, Holoshitz N, Janaszek KB, Kesarwani M, Lerman A, Prasad M, Quesada O, Reynolds HR, Savage MP, Smilowitz NR, Sutton NR, Sweeny JM, Toleva O, Henry TD, Moses JW, Fearon WF, Tremmel JA. Comprehensive Management of ANOCA, Part 1-Definition, Patient Population, and Diagnosis: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1245-1263. [PMID: 37704315 DOI: 10.1016/j.jacc.2023.06.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 06/15/2023] [Indexed: 09/15/2023]
Abstract
Angina with nonobstructive coronary arteries (ANOCA) is increasingly recognized and may affect nearly one-half of patients undergoing invasive coronary angiography for suspected ischemic heart disease. This working diagnosis encompasses coronary microvascular dysfunction, microvascular and epicardial spasm, myocardial bridging, and other occult coronary abnormalities. Patients with ANOCA often face a high burden of symptoms and may experience repeated presentations to multiple medical providers before receiving a diagnosis. Given the challenges of establishing a diagnosis, patients with ANOCA frequently experience invalidation and recidivism, possibly leading to anxiety and depression. Advances in scientific knowledge and diagnostic testing now allow for routine evaluation of ANOCA noninvasively and in the cardiac catheterization laboratory with coronary function testing (CFT). CFT includes diagnostic coronary angiography, assessment of coronary flow reserve and microcirculatory resistance, provocative testing for endothelial dysfunction and coronary vasospasm, and intravascular imaging for identification of myocardial bridging, with hemodynamic assessment as needed.
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Affiliation(s)
- Bruce A Samuels
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Samit M Shah
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - R Jay Widmer
- Baylor Scott and White Health, Temple, Texas, USA
| | - Yuhei Kobayashi
- New York Presbyterian Brooklyn Methodist Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Steven E S Miner
- Southlake Regional Medical Centre, Newmarket, Ontario, Canada; School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Allen Jeremias
- St Francis Hospital and Heart Center, Roslyn, New York, USA
| | - Ahmed Albadri
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - John A Blair
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Kathleen E Kearney
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Janet Wei
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ki Park
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Noa Holoshitz
- Ascension Columbia St Mary's, Milwaukee, Wisconsin, USA
| | | | - Manoj Kesarwani
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Megha Prasad
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York City, New York, USA
| | - Odayme Quesada
- Women's Heart Center, The Christ Hospital Heart and Vascular Institute, Cincinnati, Ohio, USA; The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, USA
| | - Harmony R Reynolds
- Sarah Ross Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York, USA
| | - Michael P Savage
- Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA; Cardiology Section, Department of Medicine, Veterans Affairs New York Harbor Healthcare System, New York, New York, USA
| | - Nadia R Sutton
- Division of Cardiovascular Medicine, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Joseph M Sweeny
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Olga Toleva
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, USA
| | - Jeffery W Moses
- St Francis Hospital and Heart Center, Roslyn, New York, USA; Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York City, New York, USA
| | - William F Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Jennifer A Tremmel
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.
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8
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Pergola V, Mattesi G, Cozza E, Pradegan N, Tessari C, Dellino CM, Savo MT, Amato F, Cecere A, Perazzolo Marra M, Tona F, Guaricci AI, De Conti G, Gerosa G, Iliceto S, Motta R. New Non-Invasive Imaging Technologies in Cardiac Transplant Follow-Up: Acquired Evidence and Future Options. Diagnostics (Basel) 2023; 13:2818. [PMID: 37685356 PMCID: PMC10487200 DOI: 10.3390/diagnostics13172818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/21/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
Heart transplantation (HT) is the established treatment for end-stage heart failure, significantly enhancing patients' survival and quality of life. To ensure optimal outcomes, the routine monitoring of HT recipients is paramount. While existing guidelines offer guidance on a blend of invasive and non-invasive imaging techniques, certain aspects such as the timing of echocardiographic assessments and the role of echocardiography or cardiac magnetic resonance (CMR) as alternatives to serial endomyocardial biopsies (EMBs) for rejection monitoring are not specifically outlined in the guidelines. Furthermore, invasive coronary angiography (ICA) is still recommended as the gold-standard procedure, usually performed one year after surgery and every two years thereafter. This review focuses on recent advancements in non-invasive and contrast-saving imaging techniques that have been investigated for HT patients. The aim of the manuscript is to identify imaging modalities that may potentially replace or reduce the need for invasive procedures such as ICA and EMB, considering their respective advantages and disadvantages. We emphasize the transformative potential of non-invasive techniques in elevating patient care. Advanced echocardiography techniques, including strain imaging and tissue Doppler imaging, offer enhanced insights into cardiac function, while CMR, through its multi-parametric mapping techniques, such as T1 and T2 mapping, allows for the non-invasive assessment of inflammation and tissue characterization. Cardiac computed tomography (CCT), particularly with its ability to evaluate coronary artery disease and assess graft vasculopathy, emerges as an integral tool in the follow-up of HT patients. Recent studies have highlighted the potential of nuclear myocardial perfusion imaging, including myocardial blood flow quantification, as a non-invasive method for diagnosing and prognosticating CAV. These advanced imaging approaches hold promise in mitigating the need for invasive procedures like ICA and EMB when evaluating the benefits and limitations of each modality.
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Affiliation(s)
- Valeria Pergola
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy; (G.M.); (C.M.D.); (M.T.S.); (F.A.); (A.C.); (M.P.M.); (F.T.); (S.I.)
| | - Giulia Mattesi
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy; (G.M.); (C.M.D.); (M.T.S.); (F.A.); (A.C.); (M.P.M.); (F.T.); (S.I.)
| | - Elena Cozza
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy; (G.M.); (C.M.D.); (M.T.S.); (F.A.); (A.C.); (M.P.M.); (F.T.); (S.I.)
| | - Nicola Pradegan
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy; (N.P.); (C.T.); (G.G.)
| | - Chiara Tessari
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy; (N.P.); (C.T.); (G.G.)
| | - Carlo Maria Dellino
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy; (G.M.); (C.M.D.); (M.T.S.); (F.A.); (A.C.); (M.P.M.); (F.T.); (S.I.)
| | - Maria Teresa Savo
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy; (G.M.); (C.M.D.); (M.T.S.); (F.A.); (A.C.); (M.P.M.); (F.T.); (S.I.)
| | - Filippo Amato
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy; (G.M.); (C.M.D.); (M.T.S.); (F.A.); (A.C.); (M.P.M.); (F.T.); (S.I.)
| | - Annagrazia Cecere
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy; (G.M.); (C.M.D.); (M.T.S.); (F.A.); (A.C.); (M.P.M.); (F.T.); (S.I.)
| | - Martina Perazzolo Marra
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy; (G.M.); (C.M.D.); (M.T.S.); (F.A.); (A.C.); (M.P.M.); (F.T.); (S.I.)
| | - Francesco Tona
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy; (G.M.); (C.M.D.); (M.T.S.); (F.A.); (A.C.); (M.P.M.); (F.T.); (S.I.)
| | - Andrea Igoren Guaricci
- Department of Emergency and Organ Transplantation, Institute of Cardiovascular Disease, University Hospital “Policlinico” of Bari, 70124 Bari, Italy;
| | | | - Gino Gerosa
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy; (N.P.); (C.T.); (G.G.)
| | - Sabino Iliceto
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy; (G.M.); (C.M.D.); (M.T.S.); (F.A.); (A.C.); (M.P.M.); (F.T.); (S.I.)
| | - Raffaella Motta
- Unit of Radiology, Department of Medicine, Medical School, University of Padua, 35122 Padua, Italy;
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9
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 182] [Impact Index Per Article: 182.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
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10
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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11
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Iwańczyk S, Woźniak P, Smukowska-Gorynia A, Araszkiewicz A, Nowak A, Jankowski M, Konwerska A, Urbanowicz T, Lesiak M. Microcirculatory Disease in Patients after Heart Transplantation. J Clin Med 2023; 12:jcm12113838. [PMID: 37298033 DOI: 10.3390/jcm12113838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 05/25/2023] [Accepted: 06/02/2023] [Indexed: 06/12/2023] Open
Abstract
Although the treatment and prognosis of patients after heart transplantation have significantly improved, late graft dysfunction remains a critical problem. Two main subtypes of late graft dysfunction are currently described: acute allograft rejection and cardiac allograft vasculopathy, and microvascular dysfunction appears to be the first stage of both. Studies revealed that coronary microcirculation dysfunction, assessed by invasive methods in the early post-transplant period, correlates with a higher risk of late graft dysfunction and death during long-term follow-up. The index of microcirculatory resistance, measured early after heart transplantation, might identify the patients at higher risk of acute cellular rejection and major adverse cardiovascular events. It may also allow optimization and enhancement of post-transplantation management. Moreover, cardiac allograft vasculopathy is an independent prognostic factor for transplant rejection and survival rate. The studies showed that the index of microcirculatory resistance correlates with anatomic changes and reflects the deteriorating physiology of the epicardial arteries. In conclusion, invasive assessment of the coronary microcirculation, including the measurement of the microcirculatory resistance index, is a promising approach to predict graft dysfunction, especially the acute allograft rejection subtype, during the first year after heart transplantation. However, further advanced studies are needed to fully grasp the importance of microcirculatory dysfunction in patients after heart transplantation.
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Affiliation(s)
- Sylwia Iwańczyk
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Patrycja Woźniak
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Anna Smukowska-Gorynia
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | | | - Alicja Nowak
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Maurycy Jankowski
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, 60-701 Poznań, Poland
- Department of Histology and Embryology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Aneta Konwerska
- Department of Histology and Embryology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Tomasz Urbanowicz
- Cardiac Surgery and Transplantology Department, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Maciej Lesiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
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12
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Shahandeh N, Song J, Saito K, Honda Y, Zimmermann FM, Ahn JM, Fearon WF, Parikh RV. Invasive Coronary Physiology in Heart Transplant Recipients: State-of-the-Art Review. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100627. [PMID: 39130712 PMCID: PMC11307478 DOI: 10.1016/j.jscai.2023.100627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/02/2023] [Accepted: 02/28/2023] [Indexed: 08/13/2024]
Abstract
Cardiac allograft vasculopathy is a leading cause of allograft failure and death among heart transplant recipients. Routine coronary angiography and intravascular ultrasound in the early posttransplant period are widely accepted as the current standard-of-care diagnostic modalities. However, many studies have now demonstrated that invasive coronary physiological assessment provides complementary long-term prognostic data and helps identify patients who are at risk of accelerated cardiac allograft vasculopathy and acute rejection.
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Affiliation(s)
- Negeen Shahandeh
- Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Justin Song
- Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Kan Saito
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Yasuhiro Honda
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | | | - Jung-Min Ahn
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - William F. Fearon
- Division of Cardiovascular Medicine, Stanford University and VA Palo Alto Health Care Systems, Stanford, California
| | - Rushi V. Parikh
- Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, California
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13
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Bart NK, Hungerford SL, McGrath-Cadell L, Macdonald PS. Case series: a cautionary tale of screening methods to detect severe cardiac allograft vasculopathy. TRANSPLANTATION REPORTS 2023. [DOI: 10.1016/j.tpr.2023.100134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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14
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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: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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15
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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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16
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Clerkin KJ, Topkara VK, Farr MA, Jain R, Colombo PC, Restaino S, Sayer G, Castillo M, Lam EY, Chernovolenko M, Yuzefpolskaya M, DeFilippis E, Latif F, Zorn E, Takeda K, Johnson LL, Uriel N, Einstein AJ. Noninvasive Physiologic Assessment of Cardiac Allograft Vasculopathy Is Prognostic for Post-Transplant Events. J Am Coll Cardiol 2022; 80:1617-1628. [PMID: 36265957 PMCID: PMC9758655 DOI: 10.1016/j.jacc.2022.08.751] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/11/2022] [Accepted: 08/10/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) causes impaired blood flow in both epicardial coronary arteries and the microvasculature. A leading cause of post-transplant mortality, CAV affects 50% of heart transplant recipients within 10 years of heart transplant. OBJECTIVES This analysis examined the outcomes of heart transplant recipients with reduced myocardial blood flow reserve (MBFR) and microvascular CAV detected by 13N-ammonia positron emission tomography (PET) myocardial perfusion imaging. METHODS A total of 181 heart transplant recipients who underwent PET to assess for CAV were included with a median follow-up of 4.7 years. Patients were classified into 2 groups according to the total MBFR: >2.0 and ≤2.0. Microvascular CAV was defined as no epicardial CAV detected by PET and/or coronary angiography, but with an MBFR ≤2.0 by PET. RESULTS In total, 71 (39%) patients had an MBFR ≤2.0. Patients with an MBFR ≤2.0 experienced an increased risk for all outcomes: 7-fold increase in death or retransplantation (HR: 7.05; 95% CI: 3.2-15.6; P < 0.0001), 12-fold increase in cardiovascular death (HR: 12.0; 95% CI: 2.64-54.12; P = 0.001), and 10-fold increase in cardiovascular hospitalization (HR: 10.1; 95% CI: 3.43-29.9; P < 0.0001). The 5-year mean survival was 302 days less than those with an MBFR >2.0 (95% CI: 260.2-345.4 days; P < 0.0001). Microvascular CAV (adjusted HR: 3.86; 95% CI: 1.58-9.40; P = 0.003) was independently associated with an increased risk of death or retransplantation. CONCLUSIONS Abnormal myocardial blood flow reserve, even in the absence of epicardial CAV, identifies patients at a high risk of death or retransplantation. Measures of myocardial blood flow provide prognostic information in addition to traditional CAV assessment.
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Affiliation(s)
- Kevin J Clerkin
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Veli K Topkara
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA. https://twitter.com/VeliKTopkaraMD
| | - Maryjane A Farr
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA. https://twitter.com/MaryjaneFarrMD
| | - Rashmi Jain
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Paolo C Colombo
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Susan Restaino
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Gabriel Sayer
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Michelle Castillo
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Elaine Y Lam
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Margarita Chernovolenko
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Melana Yuzefpolskaya
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Ersilia DeFilippis
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA. https://twitter.com/ersied727
| | - Farhana Latif
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Emmanuel Zorn
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Koji Takeda
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - Lynne L Johnson
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Nir Uriel
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA. https://twitter.com/NirUrielMD
| | - Andrew J Einstein
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA. https://twitter.com/AndrewEinstein7
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17
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Rationale and Protocol of the Multimodality Evaluation of Antibody-Mediated Injury in Heart Transplantation (LEONE-HT) Observational Cross-Sectional Study. Methods Protoc 2022; 5:mps5050075. [PMID: 36287047 PMCID: PMC9608829 DOI: 10.3390/mps5050075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/15/2022] [Accepted: 09/21/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction: Heart transplant (HT) survival has barely improved in the last decades, which is unsatisfactory for many HT recipients. The development of anti-human leukocyte antigen (anti-HLA) antibodies in HT patients is associated with a cardiac allograft dysfunction. The mechanisms leading to this damage are unclear. The Multimodality Evaluation Of Antibody-Mediated Injury In Heart Transplantation (LEONE-HT) study aimed to thoroughly describe the damage inflicted on the myocardium by anti-HLA antibodies. Methods and analysis: The LEONE-HT study is a cohort study with a cross-sectional approach in which HT patients with positive anti-HLA antibodies are compared with coetaneous HT patients with negative anti-HLA antibodies. All patients will undergo a state-of-the-art multimodal assessment, including imaging techniques, coronary anatomy and physiology evaluations and histological and immunological analyses. The individual and combined primary outcomes of structural graft injuries and longitudinal secondary outcomes are to be compared between the exposed and non-exposed groups with univariate and multivariable descriptive analyses. Ethics and dissemination: The LEONE-HT study is carried out in accordance with the principles set out in the Declaration of Helsinki and the International Conference on Harmonization guidelines for good clinical practice and following national laws and regulations. The study design, objectives and participant centers have been communicated to clinicaltrials.gov (NCT05184426). The LEONE-HT study counts on the support of patient associations to disseminate the objectives and results of the research. This study was funded by the Spanish Ministry of Science and Innovation and the Spanish Society of Cardiology.
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Zhou J, Onuma Y, Garg S, Kotoku N, Kageyama S, Masuda S, Ninomiya K, Huo Y, Reiber JHC, Tu S, Piek JJ, Escaned J, Perera D, Bourantas C, Yan H, Serruys PW. Angiography derived assessment of the coronary microcirculation: is it ready for prime time? Expert Rev Cardiovasc Ther 2022; 20:549-566. [PMID: 35899781 DOI: 10.1080/14779072.2022.2098117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Non-obstructive coronary arteries (NOCA) are present in 39.7% to 62.4% of patients who undergo elective angiography. Coronary microcirculation (<400 µm) is not visible on angiography therefore functional assessment, invasive or non-invasive plays a prior role to help provide a more personalized diagnosis of angina. AREA COVERED In this review, we revise the pathophysiology, clinical importance and invasive assessment of the coronary microcirculation, and discuss angiography-derived indices of microvascular resistance. A comprehensive literature review over four decades is also undertaken. EXPERT OPINION The coronary microvasculature plays an important role in flow autoregulation and metabolic regulation. Invasive assessment of microvascular resistance is a validated modality with independent prognostic value, nevertheless, its routine application is hampered by the requirement of intravascular instrumentation and hyperaemic agents. The angiography-derived index of microvascular resistance has emerged as a promising surrogate in pilot studies, however, more data are needed to validate and compare the diagnostic and prognostic accuracy of different equations as well as to illustrate the relationship between angiography-derived parameters for epicardial coronary arteries and those for the microvasculature.
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Affiliation(s)
- Jinying Zhou
- National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China.,Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Scot Garg
- Department of CardiologyRoyal Blackburn Hospital, Blackburn, United Kingdom
| | - Nozomi Kotoku
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Shigetaka Kageyama
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Shinichiro Masuda
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Kai Ninomiya
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Yunlong Huo
- PKU-HKUST Shenzhen-Hong Kong Institution, Shenzhen, China; Department of Cardiology, Peking University First Hospital, Beijing, China; Institute of Mechanobiology & Medical Engineering, School of Life Sciences & Biotechnology, Shanghai Jiao Tong University, Shanghai, China
| | - Johan H C Reiber
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Shengxian Tu
- School of Biomedical Engineering,Biomedical Instrument Institute Shanghai Jiao Tong University, Shanghai, China
| | - Jan J Piek
- Department of Cardiology, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - Javier Escaned
- Complutense University of Madrid Hospital Clinico San Carlos IDISCC, Madrid, Spain
| | - Divaka Perera
- Cardiovascular Division, King's College London, London, UK
| | - Christos Bourantas
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK; Institute of Cardiovascular Sciences, University College London, London, UK
| | - Hongbing Yan
- Chinese Academy of Medical Sciences, Shenzhen, China; Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital,, Beijing, China
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19
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Masarone D, Tedford RJ, Melillo E, Petraio A, Pacileo G. Angiotensin-converting enzyme inhibitor therapy after heart transplant: from molecular basis to clinical effects. Clin Transplant 2022; 36:e14696. [PMID: 35523577 DOI: 10.1111/ctr.14696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 04/19/2022] [Accepted: 04/25/2022] [Indexed: 11/29/2022]
Abstract
The use of angiotensin-converting enzyme inhibitors is an important therapy for various cardiovascular diseases, such as hypertension, ischemic heart disease and heart failure. In heart transplant recipients, angiotensin-converting enzyme inhibitors have been demonstrated to be a keystone for the treatment of hypertension with a wide spectrum of pleiotropic molecular effects ranging from improvement of the peripheral vascular system to regulation of the fluid and sodium balance. In addition, angiotensin-converting enzyme inhibitors may be also useful in the prevention of graft failure, cardiac allograft vasculopathy and chronic kidney disease progression. Further tailored multi-center and randomized studies are warranted to confirm the pleiotropic clinical effects of ACEi therapy in HTRs and to support more extended use in daily clinical practice. Finally in the near future, the use of novel pharmacological agents that inhibit the renin-angiotensin-aldosterone system such as the neprylisin inhibitor sacubitril should be investigated in heart transplant recipients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Enrico Melillo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Andrea Petraio
- Heart Transplant Unit, Department of Cardiac Surgery and Heart Transplant, AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, Naples, Italy
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20
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Spitaleri G, Brugaletta S, Potena L, Mirabet S, González-Costello J, Zucchetti O, Masetti M, Asmarats L, Gual M, Nardi E, Di Girolamo D, Campo G, Farrero M. Role of Quantitative Flow Ratio in Predicting Future Cardiac Allograft Vasculopathy in Heart Transplant Recipients. Circ Cardiovasc Interv 2022; 15:e011656. [PMID: 35580200 DOI: 10.1161/circinterventions.121.011656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coronary angiography is the gold standard for cardiac allograft vasculopathy (CAV) diagnosis, but it usually detects the disease at an advanced stage. We investigated the role of quantitative flow ratio (QFR), a noninvasive tool to identify potentially flow-limiting lesions, in predicting CAV development in heart transplant recipients. METHODS Consecutive heart transplant recipients with no evidence of angiographic CAV at baseline coronary angiography were retrospectively included between January 2010 and December 2015, and QFR computation was performed. The relationship between vessel QFR and the occurrence of angiographic vessel-related CAV (≥50% stenosis) was assessed. RESULTS One hundred forty-three patients were included and QFR computation was feasible in 241 vessels. The median value of QFR at baseline coronary angiography was 0.98 (interquartile range, 0.94-1.00). During a median follow-up of 6.0 years (interquartile range, 4.6-7.8 years), vessel-related CAV occurred in 25 (10.4%) vessels. Receiver-operating characteristic curve analysis identified a QFR best cutoff of ≤0.95 (area under the curve, 0.81 [95% CI, 0.71-0.90]; P<0.001). QFR≤0.95 was associated with an increased risk of vessel-related CAV (adjusted hazard ratio, 20.87 [95% CI, 5.35-81.43]; P<0.001). In an exploratory analysis, QFR≤0.95 in at least 2 vessels was associated with higher incidence of cardiovascular death or late graft dysfunction (71.4% in recipients with 2-3 vessels affected versus 5.1% in recipients with 0-1 vessels affected, P<0.001). CONCLUSIONS In a cohort of heart transplant recipients, QFR computation at baseline coronary angiography may be a safe and reliable tool to predict vessel-related CAV and clinical outcomes at long-term follow-up.
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Affiliation(s)
- Giosafat Spitaleri
- Heart Failure Clinic and Cardiology Service, University Hospital Germans Trias i Pujol, Badalona, Spain (G.S.).,Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain (G.S., S.B., M.F.)
| | - Salvatore Brugaletta
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain (G.S., S.B., M.F.)
| | - Luciano Potena
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy (L.P., M.M.)
| | - Sonia Mirabet
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Spain (S.M., L.A.)
| | - José González-Costello
- Advanced Heart Failure and Heart Transplant Unit, Heart Disease Institute, Bellvitge University Hospital, Bellvitge Biomedical Research Institute, Barcelona, Spain (J.G.-C., M.G.)
| | - Ottavio Zucchetti
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy (O.Z., G.C.)
| | - Marco Masetti
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy (L.P., M.M.)
| | - Lluis Asmarats
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Spain (S.M., L.A.)
| | - Miquel Gual
- Advanced Heart Failure and Heart Transplant Unit, Heart Disease Institute, Bellvitge University Hospital, Bellvitge Biomedical Research Institute, Barcelona, Spain (J.G.-C., M.G.)
| | - Elena Nardi
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (E.N.)
| | - Domenico Di Girolamo
- Cardiologia Interventistica, A.O. Sant'Anna e San Sebastiano, Caserta, Italy (D.D.G.)
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy (O.Z., G.C.).,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy (G.C.)
| | - Marta Farrero
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain (G.S., S.B., M.F.)
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21
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Kelshiker MA, Seligman H, Howard JP, Rahman H, Foley M, Nowbar AN, Rajkumar CA, Shun-Shin MJ, Ahmad Y, Sen S, Al-Lamee R, Petraco R. Coronary flow reserve and cardiovascular outcomes: a systematic review and meta-analysis. Eur Heart J 2022; 43:1582-1593. [PMID: 34849697 PMCID: PMC9020988 DOI: 10.1093/eurheartj/ehab775] [Citation(s) in RCA: 126] [Impact Index Per Article: 63.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 09/07/2021] [Accepted: 10/26/2021] [Indexed: 01/04/2023] Open
Abstract
AIMS This meta-analysis aims to quantify the association of reduced coronary flow with all-cause mortality and major adverse cardiovascular events (MACE) across a broad range of patient groups and pathologies. METHODS AND RESULTS We systematically identified all studies between 1 January 2000 and 1 August 2020, where coronary flow was measured and clinical outcomes were reported. The endpoints were all-cause mortality and MACE. Estimates of effect were calculated from published hazard ratios (HRs) using a random-effects model. Seventy-nine studies with a total of 59 740 subjects were included. Abnormal coronary flow reserve (CFR) was associated with a higher incidence of all-cause mortality [HR: 3.78, 95% confidence interval (CI): 2.39-5.97] and a higher incidence of MACE (HR 3.42, 95% CI: 2.92-3.99). Each 0.1 unit reduction in CFR was associated with a proportional increase in mortality (per 0.1 CFR unit HR: 1.16, 95% CI: 1.04-1.29) and MACE (per 0.1 CFR unit HR: 1.08, 95% CI: 1.04-1.11). In patients with isolated coronary microvascular dysfunction, an abnormal CFR was associated with a higher incidence of mortality (HR: 5.44, 95% CI: 3.78-7.83) and MACE (HR: 3.56, 95% CI: 2.14-5.90). Abnormal CFR was also associated with a higher incidence of MACE in patients with acute coronary syndromes (HR: 3.76, 95% CI: 2.35-6.00), heart failure (HR: 6.38, 95% CI: 1.95-20.90), heart transplant (HR: 3.32, 95% CI: 2.34-4.71), and diabetes mellitus (HR: 7.47, 95% CI: 3.37-16.55). CONCLUSION Reduced coronary flow is strongly associated with increased risk of all-cause mortality and MACE across a wide range of pathological processes. This finding supports recent recommendations that coronary flow should be measured more routinely in clinical practice, to target aggressive vascular risk modification for individuals at higher risk.
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Affiliation(s)
- Mihir A Kelshiker
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Henry Seligman
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Haseeb Rahman
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Michael Foley
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Alexandra N Nowbar
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Christopher A Rajkumar
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Matthew J Shun-Shin
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Yousif Ahmad
- Yale School of Medicine, Yale University, 333 Cedar St, New Haven, Connecticut 06510, USA
| | - Sayan Sen
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Ricardo Petraco
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
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22
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Wiefels C, Almufleh A, Yao J, deKemp RA, Chong AY, Mielniczuk LM, Stadnick E, Davies RA, Beanlands RS, Chih S. Prognostic utility of longitudinal quantification of PET myocardial blood flow early post heart transplantation. J Nucl Cardiol 2022; 29:712-723. [PMID: 32918246 DOI: 10.1007/s12350-020-02342-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 07/19/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Myocardial blood flow (MBF) quantification by Rubidium-82 positron emission tomography (PET) has shown promise for cardiac allograft vasculopathy (CAV) surveillance and risk stratification post heart transplantation. The objective was to determine the prognostic value of serial PET performed early post transplantation. METHODS AND RESULT Heart transplant (HT) recipients at the University of Ottawa Heart Institute with 2 PET examinations (PET1 = baseline, PET2 = follow-up) within 6 years of transplant were included in the study. Evaluation of PET flow quantification included stress MBF, coronary vascular resistance (CVR), and myocardial flow reserve (MFR). The primary composite outcome was all-cause death, re-transplant, myocardial infarction, revascularization, allograft dysfunction, cardiac allograft vasculopathy (CAV), or heart failure hospitalization. A total of 121 patients were evaluated (79% male, mean age 56 ± 11 years) with consecutive scans performed at mean 1.4 ± 0.7 and 2.6 ± 1.0 years post HT for PET1 and PET2, respectively. Over a mean follow-up of 3.0 (IQR 1.8, 4.6) years, 26 (22%) patients developed the primary outcome: 1 death, 11 new or progressive angiographic CAV, 2 percutaneous coronary interventions, 12 allograft dysfunction. Unadjusted Cox analysis showed a significant reduction in event-free survival in patients with PET1 stress MBF < 2.1 (HR: 2.43, 95% CI 1.11-5.29 P = 0.047) and persistent abnormal PET1 to PET2 CVR > 76 (HR: 2.19, 95% CI 0.87-5.51 P = 0.045). There was no association between MFR and outcomes. CONCLUSION Low-stress MBF and persistent increased CVR on serial PET imaging early post HT are associated with adverse cardiovascular outcomes. Early post-transplant and longitudinal assessment by PET may identify at-risk patients for increased surveillance post HT.
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Affiliation(s)
- Christiane Wiefels
- Cardiology, University of Ottawa Heart Institute, 40, Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
- Pós-graduação em Ciências Cardiovasculares, Universidade Federal Fluminense, Niterói, Brazil
| | - Aws Almufleh
- Cardiology, University of Ottawa Heart Institute, 40, Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
- Cardiac Sciences Department, King Saud University, Riyadh, Saudi Arabia
| | - Jason Yao
- Cardiology, University of Ottawa Heart Institute, 40, Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Robert A deKemp
- Cardiology, University of Ottawa Heart Institute, 40, Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Aun-Yeong Chong
- Cardiology, University of Ottawa Heart Institute, 40, Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Lisa Marie Mielniczuk
- Cardiology, University of Ottawa Heart Institute, 40, Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Ellamae Stadnick
- Cardiology, University of Ottawa Heart Institute, 40, Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Ross A Davies
- Cardiology, University of Ottawa Heart Institute, 40, Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Rob S Beanlands
- Cardiology, University of Ottawa Heart Institute, 40, Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Sharon Chih
- Cardiology, University of Ottawa Heart Institute, 40, Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
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23
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Ahn JM, Zimmermann FM, Arora S, Solberg OG, Angerås O, Rolid K, Rafique M, Aaberge L, Karason K, Okada K, Luikart H, Khush KK, Honda Y, Pijls NHJ, Lee SE, Kim JJ, Park SJ, Gullestad L, Fearon WF. Prognostic value of comprehensive intracoronary physiology assessment early after heart transplantation. Eur Heart J 2021; 42:4918-4929. [PMID: 34665224 PMCID: PMC8691805 DOI: 10.1093/eurheartj/ehab568] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/01/2021] [Accepted: 08/05/2021] [Indexed: 12/23/2022] Open
Abstract
AIMS We evaluated the long-term prognostic value of invasively assessing coronary physiology after heart transplantation in a large multicentre registry. METHODS AND RESULTS Comprehensive intracoronary physiology assessment measuring fractional flow reserve (FFR), the index of microcirculatory resistance (IMR), and coronary flow reserve (CFR) was performed in 254 patients at baseline (a median of 7.2 weeks) and in 240 patients at 1 year after transplantation (199 patients had both baseline and 1-year measurement). Patients were classified into those with normal physiology, reduced FFR (FFR ≤ 0.80), and microvascular dysfunction (either IMR ≥ 25 or CFR ≤ 2.0 with FFR > 0.80). The primary outcome was the composite of death or re-transplantation at 10 years. At baseline, 5.5% had reduced FFR; 36.6% had microvascular dysfunction. Baseline reduced FFR [adjusted hazard ratio (aHR) 2.33, 95% confidence interval (CI) 0.88-6.15; P = 0.088] and microvascular dysfunction (aHR 0.88, 95% CI 0.44-1.79; P = 0.73) were not predictors of death and re-transplantation at 10 years. At 1 year, 5.0% had reduced FFR; 23.8% had microvascular dysfunction. One-year reduced FFR (aHR 2.98, 95% CI 1.13-7.87; P = 0.028) and microvascular dysfunction (aHR 2.33, 95% CI 1.19-4.59; P = 0.015) were associated with significantly increased risk of death or re-transplantation at 10 years. Invasive measures of coronary physiology improved the prognostic performance of clinical variables (χ2 improvement: 7.41, P = 0.006). However, intravascular ultrasound-derived changes in maximal intimal thickness were not predictive of outcomes. CONCLUSION Abnormal coronary physiology 1 year after heart transplantation was common and was a significant predictor of death or re-transplantation at 10 years.
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Affiliation(s)
- Jung-Min Ahn
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford Cardiovascular Institute, 300 Pasteur Drive, Room H2103, Stanford, CA 94305-5218, USA
| | - Frederik M Zimmermann
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford Cardiovascular Institute, 300 Pasteur Drive, Room H2103, Stanford, CA 94305-5218, USA
- Catharina Hospital, Eindhoven, the Netherlands
| | - Satish Arora
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
- KG Jebsen Center for Cardiac Research, University of Oslo, Oslo, Norway
- Center for Heart Failure Research, Oslo University Hospital, Oslo, Norway
| | - Ole-Geir Solberg
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Katrine Rolid
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
- KG Jebsen Center for Cardiac Research, University of Oslo, Oslo, Norway
- Center for Heart Failure Research, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Muzammil Rafique
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Lars Aaberge
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Kristjan Karason
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Kozo Okada
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Helen Luikart
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford Cardiovascular Institute, 300 Pasteur Drive, Room H2103, Stanford, CA 94305-5218, USA
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford Cardiovascular Institute, 300 Pasteur Drive, Room H2103, Stanford, CA 94305-5218, USA
| | - Yasuhiro Honda
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford Cardiovascular Institute, 300 Pasteur Drive, Room H2103, Stanford, CA 94305-5218, USA
| | | | - Sang Eun Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Joong Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
- KG Jebsen Center for Cardiac Research, University of Oslo, Oslo, Norway
- Center for Heart Failure Research, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - William F Fearon
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford Cardiovascular Institute, 300 Pasteur Drive, Room H2103, Stanford, CA 94305-5218, USA
- Division of Cardiovascular Medicine, VA Palo Alto Health Care System, CA, USA
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24
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Alfonso F, Rivero F, Segovia-Cubero J. Early diagnosis of cardiac allograft vasculopathy: biopsy, liquid biopsy, non-invasive imaging, coronary imaging, or coronary physiology? Eur Heart J 2021; 42:4930-4933. [PMID: 34665226 DOI: 10.1093/eurheartj/ehab722] [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: 01/15/2023] Open
Affiliation(s)
- Fernando Alfonso
- Department of Cardiology, Hospital Universitario de La Princesa, Universidad Autónoma de Madrid, IIS-IP, CIBERCV, Madrid, Spain
| | - Fernando Rivero
- Department of Cardiology, Hospital Universitario de La Princesa, Universidad Autónoma de Madrid, IIS-IP, CIBERCV, Madrid, Spain
| | - Javier Segovia-Cubero
- Department of Cardiology, Hospital Universitario Puerta de Hierro, Majadahonda, Universidad Autónoma de Madrid, CIVERCV, Madrid, Spain
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25
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Dec GW, Narula J. Probing the Microvasculature for Long-Term Gains in Heart Transplant Recipients. J Am Coll Cardiol 2021; 78:2436-2438. [PMID: 34886964 DOI: 10.1016/j.jacc.2021.10.013] [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: 10/07/2021] [Accepted: 10/12/2021] [Indexed: 11/18/2022]
Affiliation(s)
- G William Dec
- Cardiac Unit, Massachusetts General Hospital, Boston, Massachusetts, USA; Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Jagat Narula
- Cardiac Unit, Massachusetts General Hospital, Boston, Massachusetts, USA; Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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26
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Microcirculatory Resistance Predicts Allograft Rejection and Cardiac Events After Heart Transplantation. J Am Coll Cardiol 2021; 78:2425-2435. [PMID: 34886963 DOI: 10.1016/j.jacc.2021.10.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/07/2021] [Accepted: 10/05/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Single-center data suggest that the index of microcirculatory resistance (IMR) measured early after heart transplantation predicts subsequent acute rejection. OBJECTIVES The goal of this study was to validate whether IMR measured early after transplantation can predict subsequent acute rejection and long-term outcome in a large multicenter cohort. METHODS From 5 international cohorts, 237 patients who underwent IMR measurement early after transplantation were enrolled. The primary outcome was acute allograft rejection (AAR) within 1 year after transplantation. A key secondary outcome was major adverse cardiac events (MACE) (the composite of death, re-transplantation, myocardial infarction, stroke, graft dysfunction, and readmission) at 10 years. RESULTS IMR was measured at a median of 7 weeks (interquartile range: 3-10 weeks) post-transplantation. At 1 year, the incidence of AAR was 14.4%. IMR was associated proportionally with the risk of AAR (per increase of 1-U IMR; adjusted hazard ratio [aHR]: 1.04; 95% confidence interval [CI]: 1.02-1.06; p < 0.001). The incidence of AAR in patients with an IMR ≥18 was 23.8%, whereas the incidence of AAR in those with an IMR <18 was 6.3% (aHR: 3.93; 95% CI: 1.77-8.73; P = 0.001). At 10 years, MACE occurred in 86 (36.3%) patients. IMR was significantly associated with the risk of MACE (per increase of 1-U IMR; aHR: 1.02; 95% CI: 1.01-1.04; P = 0.005). CONCLUSIONS IMR measured early after heart transplantation is associated with subsequent AAR at 1 year and clinical events at 10 years. Early IMR measurement after transplantation identifies patients at higher risk and may guide personalized posttransplantation management.
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Feher A, Sinusas AJ. Evaluation of cardiac allograft vasculopathy by positron emission tomography. J Nucl Cardiol 2021; 28:2616-2628. [PMID: 33389637 DOI: 10.1007/s12350-020-02438-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/04/2020] [Indexed: 12/22/2022]
Abstract
Cardiac allograft vasculopathy (CAV) remains one of the most important late occurring complications in heart transplant (HT) recipients significantly effecting graft survival. Recently, there has been tremendous focus on the development of effective and safe non-invasive diagnostic strategies for the diagnosis of CAV employing a wide range of imaging technologies. During the past decade multiple studies have been published using positron emission tomography (PET) myocardial perfusion imaging, establishing the value of PET myocardial blood flow quantification for the evaluation of CAV. These independent investigations demonstrate that PET can be successfully used to establish the diagnosis of CAV, can be utilized for prognostication and may be used for serial monitoring of HT recipients. In addition, molecular imaging techniques have started to emerge as new tools to enhance our knowledge to better understand the pathophysiology of CAV.
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Affiliation(s)
- Attila Feher
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, P.O. Box 208017, Dana 3, New Haven, CT, 06520, USA.
| | - Albert J Sinusas
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, P.O. Box 208017, Dana 3, New Haven, CT, 06520, USA
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
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Pober JS, Chih S, Kobashigawa J, Madsen JC, Tellides G. Cardiac allograft vasculopathy: current review and future research directions. Cardiovasc Res 2021; 117:2624-2638. [PMID: 34343276 PMCID: PMC8783389 DOI: 10.1093/cvr/cvab259] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/02/2021] [Accepted: 07/29/2021] [Indexed: 12/25/2022] Open
Abstract
Cardiac allograft vasculopathy (CAV) is a pathologic immune-mediated remodelling of the vasculature in transplanted hearts and, by impairing perfusion, is the major cause of late graft loss. Although best understood following cardiac transplantation, similar forms of allograft vasculopathy occur in other vascularized organ grafts and some features of CAV may be shared with other immune-mediated vasculopathies. Here, we describe the incidence and diagnosis, the nature of the vascular remodelling, immune and non-immune contributions to pathogenesis, current therapies, and future areas of research in CAV.
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MESH Headings
- Adaptive Immunity
- Animals
- Coronary Artery Disease/epidemiology
- Coronary Artery Disease/immunology
- Coronary Artery Disease/metabolism
- Coronary Artery Disease/pathology
- Coronary Vessels/immunology
- Coronary Vessels/metabolism
- Coronary Vessels/pathology
- Endothelial Cells/immunology
- Endothelial Cells/metabolism
- Endothelial Cells/pathology
- Graft Rejection/epidemiology
- Graft Rejection/immunology
- Graft Rejection/metabolism
- Graft Rejection/pathology
- Graft Survival
- Heart Transplantation/adverse effects
- Humans
- Immunity, Innate
- Muscle, Smooth, Vascular/immunology
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/pathology
- Myocytes, Smooth Muscle/immunology
- Myocytes, Smooth Muscle/metabolism
- Myocytes, Smooth Muscle/pathology
- Risk Factors
- Signal Transduction
- Treatment Outcome
- Vascular Remodeling
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Affiliation(s)
- Jordan S Pober
- Department of Immunobiology, Pathology and Dermatology, Yale School of Medicine, 10 Amistad Street, New Haven CT 06520-8089, USA
| | - Sharon Chih
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Jon Kobashigawa
- Department of Medicine, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Joren C Madsen
- Division of Cardiac Surgery and Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - George Tellides
- Department of Surgery (Cardiac Surgery), Yale School of Medicine, New Haven, CT, USA
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Fearon WF, Valantine HA. Can We Predict Rejection Early After Heart Transplantation? Circulation 2021; 144:1473-1475. [PMID: 34723641 DOI: 10.1161/circulationaha.121.056808] [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] [Indexed: 11/16/2022]
Affiliation(s)
- William F Fearon
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, CA (W.F.F., H.A.V.)
- VA Palo Alto Health Care System, CA (W.F.F.)
| | - Hannah A Valantine
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, CA (W.F.F., H.A.V.)
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Lee JM, Choi KH, Choi JO, Shin D, Park Y, Kim J, Lee SH, Kim D, Yang JH, Cho YH, Sung K, Choi JY, Park M, Kim JS, Park TK, Song YB, Hahn JY, Choi SH, Gwon HC, Oh JK, Jeon ES. Coronary Microcirculatory Dysfunction and Acute Cellular Rejection After Heart Transplantation. Circulation 2021; 144:1459-1472. [PMID: 34474597 DOI: 10.1161/circulationaha.121.056158] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute cellular rejection is a major determinant of mortality and retransplantation after heart transplantation. We sought to evaluate the prognostic implications of coronary microcirculatory dysfunction assessed by index of microcirculatory resistance (IMR) for the risk of acute cellular rejection after heart transplantation. METHODS The present study prospectively enrolled 154 heart transplant recipients who underwent scheduled coronary angiography and invasive coronary physiological assessment 1 month after transplantation. IMR is microcirculatory resistance under maximal hyperemia. By measuring hyperemic mean transit time using 3 injections (4 mL each) of room-temperature saline under maximal hyperemia, IMR was calculated as hyperemic distal coronary pressure×hyperemic mean transit time. The primary end point was biopsy-proven acute cellular rejection of grade ≥2R during 2 years of follow-up after transplantation and was compared by using multivariable Cox proportional hazards regression according to IMR. The incremental prognostic value of IMR, in addition to the model with clinical factors, was evaluated by comparison of C-index, net reclassification index, and integrated discrimination index. RESULTS The mean age of recipients was 51.2±13.1 years (81.2% male), and the cumulative incidence of acute cellular rejection was 19.0% at 2 years. Patients with acute cellular rejection had significantly higher IMR values at 1 month than those without acute cellular rejection (23.1±8.6 versus 16.8±11.1, P=0.002). IMR was significantly associated with the risk of acute cellular rejection (per 5-U increase: adjusted hazard ratio, 1.18 [95% CI, 1.04-1.34], P=0.011) and the optimal cutoff value of IMR to predict acute cellular rejection was 15. Patients with IMR≥15 showed significantly higher risk of acute cellular rejection than those with IMR<15 (34.4% versus 3.8%; adjusted hazard ratio, 15.3 [95% CI 3.6-65.7], P<0.001). Addition of IMR to clinical variables showed significantly higher discriminant and reclassification ability for risk of acute cellular rejection (C-index 0.87 versus 0.74, P<0.001; net reclassification index 1.05, P<0.001; integrated discrimination index 0.20, P<0.001). CONCLUSIONS Coronary microcirculatory dysfunction assessed by IMR measured early after heart transplantation showed significant association with the risk of acute cellular rejection. In addition to surveillance endomyocardial biopsy, early stratification using IMR could be a clinically useful tool to identify patients at higher risk of future acute cellular rejection after heart transplantation. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02798731.
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Affiliation(s)
- Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doosup Shin
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (D.S.)
| | - Yoonjee Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Juwon Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Internal Medicine and Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea (S.H.L.)
| | - Darae Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Medicine and Critical Care Medicine (J.H.Y.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery (Y.H.C., K.S., J.Y.C.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery (Y.H.C., K.S., J.Y.C.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Yeon Choi
- Department of Thoracic and Cardiovascular Surgery (Y.H.C., K.S., J.Y.C.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Meesoon Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Sun Kim
- Department of Pathology and Translational Genomics (J.-S.K.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae K Oh
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN (J.K.O.)
| | - Eun-Seok Jeon
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute (J.M.L., K.H.C., J.-O.C., Y.P., J.K., S.H.L., D.K., J.H.Y., M.P., T.K.P., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.K.O., E.-S.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Radico F, Gallina S, Zimarino M. Is coronary microvascular dysfunction a cause or a marker of worse outcomes in MINOCA patients? Eur J Intern Med 2021; 92:38-39. [PMID: 34246505 DOI: 10.1016/j.ejim.2021.06.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 11/22/2022]
Affiliation(s)
- Francesco Radico
- ASL 2 Abruzzo, Chieti, Italy; "G. d'Annunzio" University Chieti-Pescara, Chieti, Italy
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University Chieti-Pescara, Chieti, Italy
| | - Marco Zimarino
- "G. d'Annunzio" University Chieti-Pescara, Chieti, Italy; Cath Lab, ASL 2 Abruzzo, Chieti, Italy.
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Mileva N, Nagumo S, Gallinoro E, Sonck J, Verstreken S, Dierkcx R, Heggermont W, Bartunek J, Goethals M, Heyse A, Barbato E, De Bruyne B, Collet C, Vanderheyden M. Validation of Coronary Angiography-Derived Vessel Fractional Flow Reserve in Heart Transplant Patients with Suspected Graft Vasculopathy. Diagnostics (Basel) 2021; 11:diagnostics11101750. [PMID: 34679451 PMCID: PMC8534544 DOI: 10.3390/diagnostics11101750] [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] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 01/06/2023] Open
Abstract
Cardiac transplant-related vasculopathy remains a leading cause of morbidity and mortality in heart transplant (HTx) recipients. Recently, coronary angiography-derived vessel fractional flow reserve (vFFR) has emerged as a new diagnostic computational tool to functionally evaluate the severity of coronary artery disease. Although vFFR estimates have been shown to perform well against invasive FFR in atherosclerotic coronary artery disease, data on the use of vFFR in heart transplant recipients suffering from cardiac transplant-related arteriopathy are lacking. The aim of the presented study was to validate coronary angiography-derived vessel fractional flow reserve to calculate fractional flow reserve in HTx patients with and without cardiac transplant-related vasculopathy. A prospective, single center study of HTx patients referred for annual check-up, undergoing surveillance coronarography was conducted. Invasive FFR was measured using a motorized device at the speed of 1.0 mm/s in all three major coronary arteries. Angiography-derived pullback FFR was derived from the angiogram and compared with invasive FFR pullback curve. Overall, 18,059 FFR values were extracted from the FFR pullback curves from 23 HTx patients. The mean age was 59.3 ± 9.7 years, the mean time after transplantation was 5.24 years [IQR 1.20, 11.25]. A total of 39 vessels from 23 patients (24 LAD, 11 LCX, 4 RCA) were analyzed. Mean distal vFFR was 0.87 ± 0.14 whereas invasive distal FFR was 0.88 ± 0.17. An excellent correlation was found between invasive distal FFR and vFFR (r = 0.92; p < 0.001). The correlation of the pullback tracing was high, with a correlation coefficient between vFFR and invasive FFR pullback values of 0.72 (95% CI 0.71 to 0.73, p < 0.001). The mean difference between vFFR and invasive FFR pullback values was -0.01 with 0.06 of SD (limits of agreements -0.12 to 0.13). In HTx patients, coronary angiography-derived FFR correlates excellently with invasively measured wire-derived FFR. Therefore, angiography derived FFR could be used as a novel diagnostic tool to quantify the functional severity of graft vasculopathy.
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Affiliation(s)
- Niya Mileva
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
- Cardiology Clinic, Alexandrovska University Hospital, 1430 Sofia, Bulgaria
| | - Sakura Nagumo
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
- Department of Cardiology, Showa University Fujigaoka Hospital, Tokyo 8501, Japan
| | - Emanuele Gallinoro
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Naples, Italy
| | - Jeroen Sonck
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
- Department of Advanced Biomedical Sciences, University Federico II, 80131 Naples, Italy
| | - Sofie Verstreken
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
| | - Riet Dierkcx
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
| | - Ward Heggermont
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
| | - Jozef Bartunek
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
| | - Marc Goethals
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
| | - Alex Heyse
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
| | - Emanuele Barbato
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Naples, Italy
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
- Department of Cardiology, Lausanne University Hospital, 1100 Lausanne, Switzerland
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
| | - Marc Vanderheyden
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
- Correspondence: ; Tel.: +32-53-72-44-39
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CT-derived fractional flow reserve (FFRct) for functional coronary artery evaluation in the follow-up of patients after heart transplantation. Eur Radiol 2021; 32:1843-1852. [PMID: 34523009 PMCID: PMC8831350 DOI: 10.1007/s00330-021-08246-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/23/2021] [Accepted: 08/05/2021] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Invasively measured fractional flow reserve (FFR) is associated with outcome in heart transplant (HTx) patients. Coronary computed tomography angiography (CCTA)-derived FFR (FFRct) provides additional functional information from anatomical CT images. We describe the first use of FFRct in HTx patients. METHODS HTx patients underwent CCTA with FFRct to screen for cardiac allograft vasculopathy. FFRct was measured distal to each coronary stenosis > 30% and FFRct ≤ 0.8 indicated hemodynamically significant stenosis. FFRct was also measured at the most distal location of each vessel. Overall distal FFRct was calculated as the mean of the distal values in the left, right, and circumflex coronary artery in each patient. RESULTS Seventy-three patients (age 56 (42-65) years, 63% males) at 11 (8-16) years after HTx were included. Eighteen (25%) patients had a focal hemodynamically significant stenosis (stenosis > 30% with FFRct ≤ 0.8). In the 55 patients without a hemodynamically significant focal FFRct stenosis (FFRct > 0.80), the distal left anterior descending artery FFRct was < 0.90 in 74% of the patients and 10 (18%) patients had ≥ 1 coronary artery with a distal FFRct ≤ 0.8, including 1 with a distal FFRct ≤ 0.8 in all coronaries. Overall distal FFRct in patients without focal stenosis was 0.88 (0.86-0.91), 0.87 (0.86-0.90), and 0.88 (0.86-0.91) (median with 25th-75th percentile) at 5-9, 10-14, or ≥ 15 years post-transplantation, respectively (p = 0.93). CONCLUSIONS FFRct performed on CCTA scans of HTx patients demonstrated that 25% of patients had a focal coronary stenosis with FFRct ≤ 0.8. Even without a focal stenosis, FFRct values are often abnormal in HTx patients. KEY POINTS • This is the first report describing the use of FFRct in in heart transplant patients. • FFRct identifies patients after heart transplantation with hemodynamically significant coronary stenosis. • Even without a focal stenosis, FFRct values are often abnormal in heart transplant patients.
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Basics of Coronary Thermodilution. JACC Cardiovasc Interv 2021; 14:595-605. [PMID: 33736767 DOI: 10.1016/j.jcin.2020.12.037] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 01/15/2023]
Abstract
Coronary microvascular dysfunction is a highly prevalent condition in both obstructive and nonobstructive coronary artery disease. Intracoronary thermodilution is a promising technique to investigate coronary microvascular (dys)function in vivo and to assess its most important metric: microvascular resistance. Here, the authors provide a practical review of bolus and continuous thermodilution for the measurement of coronary flow and microvascular resistance. The authors describe the basic principles of indicator-dilution theory and of coronary thermodilution and detail the practicalities of their application in the catheterization laboratory. Finally, the authors discuss contemporary clinical applications of coronary thermodilution-based microvascular assessment in humans and future perspectives.
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Agbor-Enoh S, Shah P, Tunc I, Hsu S, Russell S, Feller E, Shah K, Rodrigo ME, Najjar SS, Kong H, Pirooznia M, Fideli U, Bikineyeva A, Marishta A, Bhatti K, Yang Y, Mutebi C, Yu K, Jang MK, Marboe C, Berry GJ, Valantine HA. Cell-Free DNA to Detect Heart Allograft Acute Rejection. Circulation 2021; 143:1184-1197. [PMID: 33435695 PMCID: PMC8221834 DOI: 10.1161/circulationaha.120.049098] [Citation(s) in RCA: 133] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 11/24/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND After heart transplantation, endomyocardial biopsy (EMBx) is used to monitor for acute rejection (AR). Unfortunately, EMBx is invasive, and its conventional histological interpretation has limitations. This is a validation study to assess the performance of a sensitive blood biomarker-percent donor-derived cell-free DNA (%ddcfDNA)-for detection of AR in cardiac transplant recipients. METHODS This multicenter, prospective cohort study recruited heart transplant subjects and collected plasma samples contemporaneously with EMBx for %ddcfDNA measurement by shotgun sequencing. Histopathology data were collected to define AR, its 2 phenotypes (acute cellular rejection [ACR] and antibody-mediated rejection [AMR]), and controls without rejection. The primary analysis was to compare %ddcfDNA levels (median and interquartile range [IQR]) for AR, AMR, and ACR with controls and to determine %ddcfDNA test characteristics using receiver-operator characteristics analysis. RESULTS The study included 171 subjects with median posttransplant follow-up of 17.7 months (IQR, 12.1-23.6), with 1392 EMBx, and 1834 %ddcfDNA measures available for analysis. Median %ddcfDNA levels decayed after surgery to 0.13% (IQR, 0.03%-0.21%) by 28 days. Also, %ddcfDNA increased again with AR compared with control values (0.38% [IQR, 0.31-0.83%], versus 0.03% [IQR, 0.01-0.14%]; P<0.001). The rise was detected 0.5 and 3.2 months before histopathologic diagnosis of ACR and AMR. The area under the receiver operator characteristic curve for AR was 0.92. A 0.25%ddcfDNA threshold had a negative predictive value for AR of 99% and would have safely eliminated 81% of EMBx. In addition, %ddcfDNA showed distinctive characteristics comparing AMR with ACR, including 5-fold higher levels (AMR ≥2, 1.68% [IQR, 0.49-2.79%] versus ACR grade ≥2R, 0.34% [IQR, 0.28-0.72%]), higher area under the receiver operator characteristic curve (0.95 versus 0.85), higher guanosine-cytosine content, and higher percentage of short ddcfDNA fragments. CONCLUSIONS We found that %ddcfDNA detected AR with a high area under the receiver operator characteristic curve and negative predictive value. Monitoring with ddcfDNA demonstrated excellent performance characteristics for both ACR and AMR and led to earlier detection than the EMBx-based monitoring. This study supports the use of %ddcfDNA to monitor for AR in patients with heart transplant and paves the way for a clinical utility study. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02423070.
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Affiliation(s)
- Sean Agbor-Enoh
- Genomic Research Alliance for Transplantation (GRAfT), 10 Center Drive, 7S261, Bethesda Maryland, 20982
- Department of Medicine, The Johns Hopkins School of Medicine, 1830 East Monument Street, Baltimore, MD
- Division of Intramural Research, National Heart, Lung and Blood Institute, 10 Center Drive, 7S261, Bethesda Maryland, 20982
| | - Palak Shah
- Genomic Research Alliance for Transplantation (GRAfT), 10 Center Drive, 7S261, Bethesda Maryland, 20982
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, VA
| | - Ilker Tunc
- Genomic Research Alliance for Transplantation (GRAfT), 10 Center Drive, 7S261, Bethesda Maryland, 20982
- Division of Intramural Research, National Heart, Lung and Blood Institute, 10 Center Drive, 7S261, Bethesda Maryland, 20982
| | - Steven Hsu
- Genomic Research Alliance for Transplantation (GRAfT), 10 Center Drive, 7S261, Bethesda Maryland, 20982
- Department of Medicine, The Johns Hopkins School of Medicine, 1830 East Monument Street, Baltimore, MD
| | - Stuart Russell
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Erika Feller
- Genomic Research Alliance for Transplantation (GRAfT), 10 Center Drive, 7S261, Bethesda Maryland, 20982
- University of Maryland Medical Center, Baltimore, MD
| | - Keyur Shah
- Genomic Research Alliance for Transplantation (GRAfT), 10 Center Drive, 7S261, Bethesda Maryland, 20982
- Virginia Commonwealth University, Richmond, VA
| | - Maria E. Rodrigo
- Genomic Research Alliance for Transplantation (GRAfT), 10 Center Drive, 7S261, Bethesda Maryland, 20982
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington DC
| | - Samer S. Najjar
- Genomic Research Alliance for Transplantation (GRAfT), 10 Center Drive, 7S261, Bethesda Maryland, 20982
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington DC
| | - Hyesik Kong
- Genomic Research Alliance for Transplantation (GRAfT), 10 Center Drive, 7S261, Bethesda Maryland, 20982
- Division of Intramural Research, National Heart, Lung and Blood Institute, 10 Center Drive, 7S261, Bethesda Maryland, 20982
| | - Mehdi Pirooznia
- Division of Intramural Research, National Heart, Lung and Blood Institute, 10 Center Drive, 7S261, Bethesda Maryland, 20982
| | - Ulgen Fideli
- Genomic Research Alliance for Transplantation (GRAfT), 10 Center Drive, 7S261, Bethesda Maryland, 20982
- Division of Intramural Research, National Heart, Lung and Blood Institute, 10 Center Drive, 7S261, Bethesda Maryland, 20982
| | - Alfiya Bikineyeva
- Genomic Research Alliance for Transplantation (GRAfT), 10 Center Drive, 7S261, Bethesda Maryland, 20982
- Division of Intramural Research, National Heart, Lung and Blood Institute, 10 Center Drive, 7S261, Bethesda Maryland, 20982
| | - Argit Marishta
- Genomic Research Alliance for Transplantation (GRAfT), 10 Center Drive, 7S261, Bethesda Maryland, 20982
- Division of Intramural Research, National Heart, Lung and Blood Institute, 10 Center Drive, 7S261, Bethesda Maryland, 20982
| | - Kenneth Bhatti
- Genomic Research Alliance for Transplantation (GRAfT), 10 Center Drive, 7S261, Bethesda Maryland, 20982
- Division of Intramural Research, National Heart, Lung and Blood Institute, 10 Center Drive, 7S261, Bethesda Maryland, 20982
| | - Yanqin Yang
- Genomic Research Alliance for Transplantation (GRAfT), 10 Center Drive, 7S261, Bethesda Maryland, 20982
- Division of Intramural Research, National Heart, Lung and Blood Institute, 10 Center Drive, 7S261, Bethesda Maryland, 20982
| | - Cedric Mutebi
- Division of Intramural Research, National Heart, Lung and Blood Institute, 10 Center Drive, 7S261, Bethesda Maryland, 20982
- Wayne State University School of Medicine, Detroit MI
| | - Kai Yu
- National Cancer Institute, Rockville, MD
| | - Moon Kyoo Jang
- Genomic Research Alliance for Transplantation (GRAfT), 10 Center Drive, 7S261, Bethesda Maryland, 20982
- Division of Intramural Research, National Heart, Lung and Blood Institute, 10 Center Drive, 7S261, Bethesda Maryland, 20982
| | - Charles Marboe
- Genomic Research Alliance for Transplantation (GRAfT), 10 Center Drive, 7S261, Bethesda Maryland, 20982
- Department of Pathology, New York Presbyterian University Hospital of Cornell and Columbia, New York, New York, USA
| | - Gerald J. Berry
- Genomic Research Alliance for Transplantation (GRAfT), 10 Center Drive, 7S261, Bethesda Maryland, 20982
- Stanford University School of Medicine, Palo Alto, CA
| | - Hannah A. Valantine
- Genomic Research Alliance for Transplantation (GRAfT), 10 Center Drive, 7S261, Bethesda Maryland, 20982
- Division of Intramural Research, National Heart, Lung and Blood Institute, 10 Center Drive, 7S261, Bethesda Maryland, 20982
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Bona M, Wyss RK, Arnold M, Méndez-Carmona N, Sanz MN, Günsch D, Barile L, Carrel TP, Longnus SL. Cardiac Graft Assessment in the Era of Machine Perfusion: Current and Future Biomarkers. J Am Heart Assoc 2021; 10:e018966. [PMID: 33522248 PMCID: PMC7955334 DOI: 10.1161/jaha.120.018966] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Heart transplantation remains the treatment of reference for patients experiencing end‐stage heart failure; unfortunately, graft availability through conventional donation after brain death is insufficient to meet the demand. Use of extended‐criteria donors or donation after circulatory death has emerged to increase organ availability; however, clinical protocols require optimization to limit or prevent damage in hearts possessing greater susceptibility to injury than conventional grafts. The emergence of cardiac ex situ machine perfusion not only facilitates the use of extended‐criteria donor and donation after circulatory death hearts through the avoidance of potentially damaging ischemia during graft storage and transport, it also opens the door to multiple opportunities for more sensitive monitoring of graft quality. With this review, we aim to bring together the current knowledge of biomarkers that hold particular promise for cardiac graft evaluation to improve precision and reliability in the identification of hearts for transplantation, thereby facilitating the safe increase in graft availability. Information about the utility of potential biomarkers was categorized into 5 themes: (1) functional, (2) metabolic, (3) hormone/prohormone, (4) cellular damage/death, and (5) inflammatory markers. Several promising biomarkers are identified, and recommendations for potential improvements to current clinical protocols are provided.
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Affiliation(s)
- Martina Bona
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Rahel K Wyss
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Maria Arnold
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Natalia Méndez-Carmona
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Maria N Sanz
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Dominik Günsch
- Department of Anesthesiology and Pain Medicine/Institute for Diagnostic, Interventional and Paediatric Radiology Bern University HospitalInselspitalUniversity of Bern Switzerland
| | - Lucio Barile
- Laboratory for Cardiovascular Theranostics Cardiocentro Ticino Foundation and Faculty of Biomedical Sciences Università Svizzera Italiana Lugano Switzerland
| | - Thierry P Carrel
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Sarah L Longnus
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
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Abstract
Heart transplantation (HTx) remains the optimal treatment for selected patients with end-stage advanced heart failure. However, survival is limited early by acute rejection and long term by cardiac allograft vasculopathy (CAV). Even though the diagnosis of rejection is based on histology, cardiac imaging provides a pivotal role for early detection and severity assessment of these hazards. The present review focuses on the use and reliability of different invasive and non-invasive imaging modalities to detect and monitor CAV and rejection after HTx. Coronary angiography remains the corner stone in routine CAV surveillance. However, angiograms are invasive and underestimates the CAV severity especially in the early phase. Intravascular ultrasound and optical coherence tomography are invasive methods for intracoronary imaging that detects early CAV lesions not evident by angiograms. Non-invasive imaging can be divided into myocardial perfusion imaging, anatomical/structural imaging and myocardial functional imaging. The different non-invasive imaging modalities all provide clinical and prognostic information and may have a gatekeeper role for invasive monitoring. Acute rejection and CAV are still significant clinical problems after HTx. No imaging modality provides complete information on graft function, coronary anatomy and myocardial perfusion. However, a combination of invasive and non-invasive modalities at different stages following HTx should be considered for optimal personalized surveillance and risk stratification.
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Affiliation(s)
| | | | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Denmark
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Chih S, McDonald M, Dipchand A, Kim D, Ducharme A, Kaan A, Abbey S, Toma M, Anderson K, Davey R, Mielniczuk L, Campbell P, Zieroth S, Bourgault C, Badiwala M, Clarke B, Belanger E, Carrier M, Conway J, Doucette K, Giannetti N, Isaac D, MacArthur R, Senechal M. Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement on Heart Transplantation: Patient Eligibility, Selection, and Post-Transplantation Care. Can J Cardiol 2020; 36:335-356. [PMID: 32145863 DOI: 10.1016/j.cjca.2019.12.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/17/2022] Open
Abstract
Significant practice-changing developments have occurred in the care of heart transplantation candidates and recipients over the past decade. This Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement provides evidence-based, expert panel recommendations with values and preferences, and practical tips on: (1) patient selection criteria; (2) selected patient populations; and (3) post transplantation surveillance. The recommendations were developed through systematic review of the literature and using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The evolving areas of importance addressed include transplant recipient age, frailty assessment, pulmonary hypertension evaluation, cannabis use, combined heart and other solid organ transplantation, adult congenital heart disease, cardiac amyloidosis, high sensitization, and post-transplantation management of antibodies to human leukocyte antigen, rejection, cardiac allograft vasculopathy, and long-term noncardiac care. Attention is also given to Canadian-specific management strategies including the prioritization of highly sensitized transplant candidates (status 4S) and heart organ allocation algorithms. The focus topics in this position statement highlight the increased complexity of patients who undergo evaluation for heart transplantation as well as improved patient selection, and advances in post-transplantation management and surveillance that have led to better long-term outcomes for heart transplant recipients.
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Affiliation(s)
- Sharon Chih
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - Michael McDonald
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Anne Dipchand
- Labatt Family Heart Centre, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Kim
- University of Alberta, Edmonton, Alberta, Canada
| | - Anique Ducharme
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Susan Abbey
- Centre for Mental Health, University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Mustafa Toma
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Kim Anderson
- Halifax Infirmary, Department of Medicine-Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ryan Davey
- University of Western Ontario, London, Ontario, Canada
| | - Lisa Mielniczuk
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | - Christine Bourgault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec
| | - Mitesh Badiwala
- Peter Munk Cardiac Centre, University Health Network and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Michel Carrier
- Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jennifer Conway
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Debra Isaac
- University of Calgary, Calgary, Alberta, Canada
| | | | - Mario Senechal
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), Université Laval, Laval, Québec, Canada
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Cziráki A, Lenkey Z, Sulyok E, Szokodi I, Koller A. L-Arginine-Nitric Oxide-Asymmetric Dimethylarginine Pathway and the Coronary Circulation: Translation of Basic Science Results to Clinical Practice. Front Pharmacol 2020; 11:569914. [PMID: 33117166 PMCID: PMC7550781 DOI: 10.3389/fphar.2020.569914] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/03/2020] [Indexed: 12/16/2022] Open
Abstract
By 1980, it was thought that we already knew most of the major mechanisms regulating vascular tone. However, after the somewhat serendipity discovery that endothelium is involved in mediation of relaxation to acetylcholine, a whole new world opened up and we had to rewrite our concept regarding vascular function and its regulation (not to mention many other fields). The new player was an endothelium derived relaxing factor, which molecular constitution has been identified to be nitric oxide (NO). This review summarizes the major molecular steps concerning how NO is synthetized from L-arginine. Also, the fate of L-arginine is described via the arginase and methylation pathways; both of them are affecting substantially the level and efficacy of NO. In vitro and in vivo effects of L-arginine are summarized and controversial clinical findings are discussed. On the basis of the use of methylated L-arginines, the vasomotor effects of endothelial NO released to agonists and increases in flow/wall shear stress (a major biological stimulus) is summarized. In this review the role of NO in the regulation of coronary vascular resistance, hence blood flow, is delineated and the somewhat questionable clinical use of NO donors is discussed. We made an attempt to summarize the biosynthesis, role, and molecular mechanisms of endogenously produced methylated L-arginine, asymmetric dimethylarginine (ADMA) in modulating vascular resistance, affecting the function of the heart. Additionally, the relationship between ADMA level and various cardiovascular diseases is described, such as atherosclerosis, coronary artery disease (CAD), ischemia/reperfusion injuries, and different types of coronary revascularization. A novel aspect of coronary vasomotor regulation is identified in which the pericardial fluid ADMA and endothelin play putative roles. Finally, some of the open possibilities for future research on L-arginine-NO-ADMA signaling are highlighted.
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Affiliation(s)
- Attila Cziráki
- Medical School, Heart Institute, University of Pécs, Pécs, Hungary.,Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Zsófia Lenkey
- Medical School, Heart Institute, University of Pécs, Pécs, Hungary
| | - Endre Sulyok
- Institute of Public Health and Health Promotion, University of Pécs, Pécs, Hungary
| | - István Szokodi
- Medical School, Heart Institute, University of Pécs, Pécs, Hungary.,Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Akos Koller
- Department of Morphology and Physiology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary.,Research Center for Sports Physiology, University of Physical Education, Budapest, Hungary.,Department of Physiology, New York Medical College, Valhalla, NY, United States
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40
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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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Vessel Fractional Flow Reserve and Graft Vasculopathy in Heart Transplant Recipients. J Interv Cardiol 2020; 2020:9835151. [PMID: 32733172 PMCID: PMC7376430 DOI: 10.1155/2020/9835151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 05/12/2020] [Indexed: 11/18/2022] Open
Abstract
Background Cardiac allograft vasculopathy (CAV) remains the Achilles' heel of long-term survival after heart transplantation (HTx). The severity and extent of CAV is graded with conventional coronary angiography (COR) which has several limitations. Recently, vessel fractional flow reserve (vFFR) derived from COR has emerged as a diagnostic computational tool to quantify the functional severity of coronary artery disease. Purpose The present study assessed the usefulness of vFFR to detect CAV in HTx recipients. Methods In HTx patients referred for annual check-up, undergoing surveillance COR, the extent of CAV was graded according to the criteria proposed by the international society of heart and lung transplantation (ISHLT). In addition, three-dimensional coronary geometries were constructed from COR to calculate pressure losses using vFFR. Results In 65 HTx patients with a mean age of 53.7 ± 10.1 years, 8.5 years (IQR 1.90, 15.2) years after HTx, a total number of 173 vessels (59 LAD, 61 LCX, and 53 RCA) were analyzed. The mean vFFR was 0.84 ± 0.15 and median was 0.88 (IQR 0.79, 0.94). A vFFR ≤ 0.80 was present in 24 patients (48 vessels). HTx patients with a history of ischemic cardiomyopathy (ICMP) had numerically lower vFFR as compared to those with non-ICMP (0.70 ± 0.22 vs. 0.79 ± 0.13, p = 0.06). The use of vFFR reclassified 31.9% of patients compared to the anatomical ISHLT criteria. Despite a CAV score of 0, a pathological vFFR ≤ 0.80 was detected in 8 patients (34.8%). Conclusion The impairment in epicardial conductance assessed by vFFR in a subgroup of patients without CAV according to standard ISHLT criteria suggests the presence of a diffuse vasculopathy undetectable by conventional angiography. Therefore, we speculate that vFFR may be useful in risk stratification after HTx.
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Suda A, Takahashi J, Hao K, Kikuchi Y, Shindo T, Ikeda S, Sato K, Sugisawa J, Matsumoto Y, Miyata S, Sakata Y, Shimokawa H. Coronary Functional Abnormalities in Patients With Angina and Nonobstructive Coronary Artery Disease. J Am Coll Cardiol 2020; 74:2350-2360. [PMID: 31699275 DOI: 10.1016/j.jacc.2019.08.1056] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/20/2019] [Accepted: 08/26/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Approximately one-half of patients undergoing diagnostic coronary angiography for angina have no significant coronary stenosis, in whom coronary functional abnormalities could be involved. OBJECTIVES This study examined the significance of coronary functional abnormalities in a comprehensive manner for both epicardial and microvascular coronary arteries in patients with angina and nonobstructive coronary artery disease (CAD). METHODS This study prospectively enrolled 187 consecutive patients (male/female 113/74, 63.2 ± 12.3 years), who underwent acetylcholine provocation test for coronary spasm and measurement of index of microcirculatory resistance (IMR) to evaluate coronary microvascular function, and followed them for a median of 893 days. RESULTS Of all subjects, acetylcholine test identified 128 patients with vasospastic angina (VSA) (68%), and cardiac events occurred in 10 patients (5.3%) during the follow-up. Multivariable analysis revealed that IMR correlated with the incidence of cardiac events (hazard ratio: 1.05; 95% confidence interval: 1.02 to 1.09; p = 0.002) and receiver-operating characteristics (ROC) curve analysis identified IMR of 18.0 as the optimal cut-off value. Among the 4 groups based on the cut-off value of IMR and the presence of VSA, the Kaplan-Meier survival analysis showed a significantly worse prognosis in the group with high IMR (≥18.0) and VSA compared with other groups (log rank, p = 0.002). Importantly, intracoronary administration of fasudil, a Rho-kinase inhibitor, significantly ameliorated IMR in the VSA patients with increased IMR (p < 0.0001). CONCLUSIONS These results indicate that in patients with angina and nonobstructive CAD, coexistence of epicardial coronary spasm and increased microvascular resistance is associated with worse prognosis, for which Rho-kinase activation may be involved.
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Affiliation(s)
- Akira Suda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kiyotaka Hao
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoku Kikuchi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomohiko Shindo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shohei Ikeda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Koichi Sato
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jun Sugisawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuharu Matsumoto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Satoshi Miyata
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiko Sakata
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
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The role of optical coherence tomography and other intravascular imaging modalities in cardiac allograft vasculopathy. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2020; 16:19-29. [PMID: 32368233 PMCID: PMC7189132 DOI: 10.5114/aic.2020.93909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/13/2020] [Indexed: 11/17/2022] Open
Abstract
Orthotopic heart transplantation (OHT) is the standard-of-care for end-stage heart disease. Although a significant improvement in the prognosis of patients after OHT has been observed in recent years, their overall mortality remains relatively high, with a median survival of approximately 10 years after transplantation. One of the primary causes of death in patients after OHT is cardiac allograft vasculopathy (CAV), the condition developing specifically in the coronary vasculature after OHT, the pathophysiology of which is still inadequately known. It is estimated that CAV development and progression is responsible for approximately 30% of deaths within five years post-OHT. According to the International Society for Heart and Lung Transplantation (ISHLT) Nomenclature for CAV, its presence should be assessed primarily by the coronary angiography performed routinely after OHT, mostly due to its wide availability, reproducibility, and low complication rate. However, the analysis of CAV in coronary angiography has limitations, mostly concerning its - sometimes inadequate - sensitivity and specificity. Hence, there is a growing need for the introduction of more accurate methods of CAV assessment, such as intravascular imaging, which through a thorough evaluation of the arterial wall structure and thickness allows the drawbacks of routine angiography to be minimised. The aim of the article was to critically summarise the current findings derived from the analysis of CAV by optical coherence tomography, the other intravascular imaging modalities, such as intravascular ultrasound (IVUS) and IVUS-derived virtual histology, along with physiological assessment with the use of the fractional flow reserve.
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Arashi H, Sato T, Kobashigawa J, Luikart H, Kobayashi Y, Okada K, Sinha S, Honda Y, Yeung AC, Khush K, Fearon WF. Long-term clinical outcomes with use of an angiotensin-converting enzyme inhibitor early after heart transplantation. Am Heart J 2020; 222:30-37. [PMID: 32007823 DOI: 10.1016/j.ahj.2020.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/04/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The safety and efficacy of angiotensin converting enzyme inhibition (ACEI) after heart transplantation (HT) is unknown. This study examined long-term clinical outcomes after ACEI in HT recipients. METHODS The ACEI after HT study was a prospective, randomized trial that tested the efficacy of ACEI with ramipril after HT. In this study, long-term clinical outcomes were assessed in 91 patients randomized to either ramipril or placebo (median, 5.8 years). The primary endpoint was a composite of death, retransplantation, hospitalization for rejection or heart failure, and coronary revascularization. RESULTS The primary endpoint occurred in 10 of 45 patients (22.2%) in the ramipril group and in 14 of 46 patients (30.4%) in the placebo group (Hazard ratio (HR), 0.68; 95% CI, 0.29-1.51; P = .34). When the analysis was restricted to comparing patients who remained on a renin-angiotensin system inhibitor beyond 1 year with those who did not, there was a trend to improved outcomes (HR, 0.54; 95% CI, 0.22-1.28, P = .16). There was no significant difference in creatinine, blood urea nitrogen, and potassium at 3 years after randomization. The cumulative incidence of the primary endpoint was significantly higher in patients in whom the index of microcirculatory resistance increased from baseline to 1 year compared with those in whom it did not (39.1 vs 17.4%, HR: 3.36; 95% CI, 1.07-12.7; P = .037). CONCLUSION The use of ramipril after HT safely lowers blood pressure and is associated with favorable long-term clinical outcomes. Clinical Trial Registration-URL: https://www.clinicaltrials.gov. Unique identifier: NCT01078363.
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DeSa TB, Abbasi MA, Blaisdell JA, Lin K, Collins JD, Carr JC, Markl M. Semi-quantitative myocardial perfusion MRI in heart transplant recipients at rest: repeatability in healthy controls and assessment of cardiac allograft vasculopathy. Clin Imaging 2019; 61:62-68. [PMID: 31981959 DOI: 10.1016/j.clinimag.2019.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 11/25/2019] [Accepted: 12/16/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cardiac Allograft Vasculopathy (CAV) is a major cause of chronic cardiac allograft failure. Invasive coronary angiography (ICA) and intravascular ultrasound (IVUS) are the current diagnostic methods. Myocardial perfusion MRI has become a promising non-invasive method to evaluate myocardial ischemia, but has not been thoroughly validated in CAV. Our objective was to assess the repeatability of myocardial rest-perfusion MRI in healthy volunteers and its feasibility in detecting CAV in transplant patients (Tx). METHODS Twelve healthy volunteers and twenty transplant patients beyond the first year post- transplant underwent cardiac MRI at 1.5 T at rest including first-pass perfusion imaging in short axis (base, mid, apex) after injection of gadolinium. Volunteers underwent repeated cardiac MRI on different days (interval = 15.6 ± 2.4 days) to assess repeatability. Data analysis included semi-automatic contouring of endocardial and epicardial borders of the left ventricle (LV) and quantification of peak perfusion, time-to-peak (TTP) perfusion, and upslope of the perfusion curve. RESULTS Between scans and re-scans in healthy volunteers, peak signal intensity, slope, and TTP demonstrated moderate agreement (ICC = 0.53, 0.48, and 0.59, respectively; all, p < .001). Peak signal intensity, slope, and TTP were moderately variable with COV values of 23%, 42%, and 35%, respectively. Peak perfusion was significantly reduced in CAV positive (n = 9 Tx patients) compared to CAV negative (n = 11 Tx patients) groups (90.7 ± 27.0 vs 139.5 ± 30.2, p < .001). CONCLUSION Cardiac MRI is a moderately repeatable method for the semi-quantitative assessment of first-pass myocardial perfusion at rest. Semi-quantitative surrogate markers of LV perfusion could play a role in CAV detection.
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Affiliation(s)
- Travis B DeSa
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA.
| | - Muhannad A Abbasi
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA
| | - Julie A Blaisdell
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA
| | - Kai Lin
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA
| | - Jeremy D Collins
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA; Mayo Clinic, Department of Radiology, Rochester, MN, USA
| | - James C Carr
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA
| | - Michael Markl
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA; Northwestern University McCormick School of Engineering, Department of Biomedical Engineering, 2145 Sheridan Rd, Evanston, IL 60208, USA
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Qin G, Wohlfart B, Zuo L, Hu J, Sjöberg T, Steen S. Intact coronary and myocardial functions after 24 hours of non-ischemic heart preservation. SCAND CARDIOVASC J 2019; 54:59-65. [DOI: 10.1080/14017431.2019.1684553] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Guangqi Qin
- Department of Cardiothoracic Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Björn Wohlfart
- Department of Cardiothoracic Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Long Zuo
- Department of Cardiothoracic Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Jingfeng Hu
- Department of Cardiothoracic Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Trygve Sjöberg
- Department of Cardiothoracic Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Stig Steen
- Department of Cardiothoracic Surgery, Lund University and Skåne University Hospital, Lund, Sweden
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Parikh RV, Fearon WF. Adrenomedullin and endothelin-1: Promising biomarkers of endothelial function, but not ready for prime time. Int J Cardiol 2019; 291:175-176. [DOI: 10.1016/j.ijcard.2019.05.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 05/21/2019] [Indexed: 11/17/2022]
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Okada K, Honda Y, Luikart H, Yock PG, Fitzgerald PJ, Yeung AC, Valantine HA, Khush KK, Fearon WF. Early invasive assessment of the coronary microcirculation predicts subsequent acute rejection after heart transplantation. Int J Cardiol 2019; 290:27-32. [DOI: 10.1016/j.ijcard.2019.04.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 03/12/2019] [Accepted: 04/05/2019] [Indexed: 10/27/2022]
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Nishi T, Murai T, Ciccarelli G, Shah SV, Kobayashi Y, Derimay F, Waseda K, Moonen A, Hoshino M, Hirohata A, Yong AS, Ng MK, Amano T, Barbato E, Kakuta T, Fearon WF. Prognostic Value of Coronary Microvascular Function Measured Immediately After Percutaneous Coronary Intervention in Stable Coronary Artery Disease. Circ Cardiovasc Interv 2019; 12:e007889. [DOI: 10.1161/circinterventions.119.007889] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background:
The prognostic impact of coronary microvascular dysfunction after percutaneous coronary intervention (PCI) remains unclear in patients with stable coronary artery disease. This study sought to investigate the prognostic value of microvascular function measured immediately after PCI in patients with stable coronary artery disease.
Methods:
We enrolled 572 patients with stable coronary artery disease who underwent PCI and elective measurement of the index of microcirculatory resistance (IMR) immediately after PCI from 8 centers in 4 countries. Impaired microvascular function was defined as IMR≥25 (high IMR). Major adverse cardiac events, including death, myocardial infarction (MI) and target vessel revascularization, were evaluated.
Results:
During a median follow-up duration of 4.0 years, the cumulative major adverse cardiac events rate was significantly higher in the high IMR group (n=66/148) compared with the low IMR group (n=128/424; hazard ratio [HR], 1.56; 95% CI, 1.16−2.105;
P
=0.001), primarily due to a higher rate of periprocedural MI (HR, 1.59; 95% CI, 1.11−2.28;
P
=0.004) but also due to higher rates of mortality (HR, 1.59; 95% CI, 0.76−3.35;
P
=0.22), spontaneous MI (HR, 2.10; 95% CI, 0.67−6.63;
P
=0.20) and target vessel revascularization (HR, 1.40; 95% CI, 0.77−2.54;
P
=0.27). Cumulative risk for death, spontaneous MI, and target vessel revascularization was higher in the high IMR group (HR, 1.55; 95% CI, 0.99−2.43;
P
=0.056), as was death and spontaneous MI alone (HR, 1.79; 95% CI, 0.96−3.36;
P
=0.065). On multivariable analysis, high IMR post-PCI was an independent predictor of major adverse cardiac events.
Conclusions:
IMR measured immediately after PCI predicts adverse events in patients with stable coronary artery disease.
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Affiliation(s)
- Takeshi Nishi
- Division of Cardiovascular Medicine, Stanford University School of Medicine and Stanford Cardiovascular Institute, CA (T.N., S.V.S., Y.K., F.D., W.F.F.)
| | - Tadashi Murai
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan (T.M., M.H., T.K.)
| | | | - Sonia V. Shah
- Division of Cardiovascular Medicine, Stanford University School of Medicine and Stanford Cardiovascular Institute, CA (T.N., S.V.S., Y.K., F.D., W.F.F.)
| | - Yuhei Kobayashi
- Division of Cardiovascular Medicine, Stanford University School of Medicine and Stanford Cardiovascular Institute, CA (T.N., S.V.S., Y.K., F.D., W.F.F.)
| | - François Derimay
- Division of Cardiovascular Medicine, Stanford University School of Medicine and Stanford Cardiovascular Institute, CA (T.N., S.V.S., Y.K., F.D., W.F.F.)
| | - Katsuhisa Waseda
- Department of Cardiology, Aichi Medical University, Nagakute, Japan (K.W., T.A.)
| | - Avalon Moonen
- Department of Cardiology, Concord Hospital, Sydney, Australia (A.M., A.S.C.Y.)
- Sydney Medical School, The University of Sydney, Australia (A.M., A.S.C.Y., M.K.C.N.)
| | - Masahiro Hoshino
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan (T.M., M.H., T.K.)
| | - Atsushi Hirohata
- Department of Cardiovascular Medicine, Sakakibara Heart Institute of Okayama, Japan (A.H.)
| | - Andy S.C. Yong
- Department of Cardiology, Concord Hospital, Sydney, Australia (A.M., A.S.C.Y.)
- Sydney Medical School, The University of Sydney, Australia (A.M., A.S.C.Y., M.K.C.N.)
| | - Martin K.C. Ng
- Sydney Medical School, The University of Sydney, Australia (A.M., A.S.C.Y., M.K.C.N.)
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (M.K.C.N.)
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Nagakute, Japan (K.W., T.A.)
| | - Emanuele Barbato
- Cardiovascular Center Aalst, Belgium (G.C., E.B.)
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Tsunekazu Kakuta
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan (T.M., M.H., T.K.)
| | - William F. Fearon
- Division of Cardiovascular Medicine, Stanford University School of Medicine and Stanford Cardiovascular Institute, CA (T.N., S.V.S., Y.K., F.D., W.F.F.)
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50
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Xaplanteris P, Fournier S, Keulards DCJ, Adjedj J, Ciccarelli G, Milkas A, Pellicano M, Van't Veer M, Barbato E, Pijls NHJ, De Bruyne B. Catheter-Based Measurements of Absolute Coronary Blood Flow and Microvascular Resistance: Feasibility, Safety, and Reproducibility in Humans. Circ Cardiovasc Interv 2019; 11:e006194. [PMID: 29870386 DOI: 10.1161/circinterventions.117.006194] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 01/29/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND The principle of continuous thermodilution can be used to calculate absolute coronary blood flow and microvascular resistance (R). The aim of the study is to explore the safety, feasibility, and reproducibility of coronary blood flow and R measurements as measured by continuous thermodilution in humans. METHODS AND RESULTS Absolute coronary flow and R can be calculated by thermodilution by infusing saline at room temperature through a dedicated monorail catheter. The temperature of saline as it enters the vessel, the temperature of blood and saline mixed in the distal part of the vessel, and the distal coronary pressure were measured by a pressure/temperature sensor-tipped guidewire. The feasibility and safety of the method were tested in 135 patients who were referred for coronary angiography. No significant adverse events were observed; in 11 (8.1%) patients, bradycardia and concomitant atrioventricular block appeared transiently and were reversed immediately on interruption of the infusion. The reproducibility of measurements was tested in a subgroup of 80 patients (129 arteries). Duplicate measurements had a strong correlation both for coronary blood flow (ρ=0.841, P<0.001; intraclass correlation coefficient=0.89, P<0.001) and R (ρ=0.780, P<0.001; intraclass correlation coefficient=0.89, P<0.001). In Bland-Altman plots, there was no significant bias or asymmetry. CONCLUSIONS Absolute coronary blood flow (in L/min) and R (in mm Hg/L/min or Wood units) can be safely and reproducibly measured with continuous thermodilution. This approach constitutes a new opportunity for the study of the coronary microcirculation.
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Affiliation(s)
- Panagiotis Xaplanteris
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Stephane Fournier
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Daniëlle C J Keulards
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Julien Adjedj
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Giovanni Ciccarelli
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Anastasios Milkas
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Mariano Pellicano
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Marcel Van't Veer
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Emanuele Barbato
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Nico H J Pijls
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Bernard De Bruyne
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.).
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