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Bacich D, Tessari C, Ciccarelli G, Lucertini G, Cerutti A, Pradegan N, Toscano G, Di Salvo G, Gambino A, Gerosa G. A Comprehensive Excursus of the Roles of Echocardiography in Heart Transplantation Follow-Up. J Clin Med 2024; 13:3205. [PMID: 38892916 PMCID: PMC11172807 DOI: 10.3390/jcm13113205] [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: 04/24/2024] [Revised: 05/23/2024] [Accepted: 05/27/2024] [Indexed: 06/21/2024] Open
Abstract
Current guidelines for the care of heart transplantation recipients recommend routine endomyocardial biopsy and invasive coronary angiography as the cornerstones in the surveillance for acute rejection (AR) and coronary allograft vasculopathy (CAV). Non-invasive tools, including coronary computed tomography angiography and cardiac magnetic resonance, have been introduced into guidelines without roles of their own as gold standards. These techniques also carry the risk of contrast-related kidney injury. There is a need to explore non-invasive approaches providing valuable information while minimizing risks and allowing their application independently of patient comorbidities. Echocardiographic examination can be performed at bedside, serially repeated, and does not carry the burden of contrast-related kidney injury and procedure-related risk. It provides comprehensive assessment of cardiac morphology and function. Advanced echocardiography techniques, including Doppler tissue imaging and strain imaging, may be sensitive tools for the detection of minor myocardial dysfunction, thus providing insight into early detection of AR and CAV. Stress echocardiography may offer a valuable tool in the detection of CAV, while the assessment of coronary flow reserve can unravel coronary microvascular impairment and add prognostic value to conventional stress echocardiography. The review highlights the role of Doppler echocardiography in heart transplantation follow-up, weighting advantages and limitations of the different techniques.
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Affiliation(s)
- Daniela Bacich
- Cardiac Surgery Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University Hospital of Padova, 35128 Padova, Italy; (D.B.); (G.C.); (G.L.); (N.P.); (G.T.); (A.G.); (G.G.)
| | - Chiara Tessari
- Cardiac Surgery Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University Hospital of Padova, 35128 Padova, Italy; (D.B.); (G.C.); (G.L.); (N.P.); (G.T.); (A.G.); (G.G.)
| | - Giulia Ciccarelli
- Cardiac Surgery Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University Hospital of Padova, 35128 Padova, Italy; (D.B.); (G.C.); (G.L.); (N.P.); (G.T.); (A.G.); (G.G.)
| | - Giovanni Lucertini
- Cardiac Surgery Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University Hospital of Padova, 35128 Padova, Italy; (D.B.); (G.C.); (G.L.); (N.P.); (G.T.); (A.G.); (G.G.)
| | - Alessia Cerutti
- Pediatric Cardiology Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (A.C.); (G.D.S.)
| | - Nicola Pradegan
- Cardiac Surgery Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University Hospital of Padova, 35128 Padova, Italy; (D.B.); (G.C.); (G.L.); (N.P.); (G.T.); (A.G.); (G.G.)
| | - Giuseppe Toscano
- Cardiac Surgery Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University Hospital of Padova, 35128 Padova, Italy; (D.B.); (G.C.); (G.L.); (N.P.); (G.T.); (A.G.); (G.G.)
| | - Giovanni Di Salvo
- Pediatric Cardiology Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (A.C.); (G.D.S.)
| | - Antonio Gambino
- Cardiac Surgery Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University Hospital of Padova, 35128 Padova, Italy; (D.B.); (G.C.); (G.L.); (N.P.); (G.T.); (A.G.); (G.G.)
| | - Gino Gerosa
- Cardiac Surgery Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University Hospital of Padova, 35128 Padova, Italy; (D.B.); (G.C.); (G.L.); (N.P.); (G.T.); (A.G.); (G.G.)
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Sciaccaluga C, Mandoli GE, Sisti N, Natali MB, Ibrahim A, Menci D, D'Errico A, Donati G, Benfari G, Valente S, Bernazzali S, Maccherini M, Mondillo S, Cameli M, Focardi M. Detection of cardiac allograft vasculopathy by multi-layer left ventricular longitudinal strain in heart transplant recipients. Int J Cardiovasc Imaging 2021; 37:1621-1628. [PMID: 33442856 DOI: 10.1007/s10554-020-02147-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 12/24/2020] [Indexed: 11/30/2022]
Abstract
Cardiac allograft vasculopathy (CAV) is an obliterative and diffuse type of coronaropathy that develops in the transplanted human heart, representing a major cause of graft failure and mortality. Nowadays the gold standard for the diagnosis of CAV is coronary angiography (CA). Non-invasive CAV detection, especially in the early stages of the disease, is still challenging. Our study aimed to investigate the role of speckle tracking echocardiography (STE), in particular three-layer STE, in predicting CAV at early stages, and if other traditional echocardiographic, clinical or biochemical parameters could relate to CAV. The study population was composed of a total of 33 heart transplanted patients, divided accordingly to the presence or absence of CAV (12 CAV+ , 22 CAV-). All subjects underwent a complete transthoracic echocardiographic examination on the same day of the CA, and all conventional parameters of myocardial function were obtained, including strain values assessed by STE. Strain values were significantly reduced in presence of CAV, at each myocardial layer but in particular the endocardial-epicardial gradient (- 4.15 ± 1.6 vs - 1.7 ± 0.4% < .0001) that was also highly predictive of CAV (AUC at ROC curve 0.97). Among diastolic parameters, the E wave deceleration time (DT) and the mean E/e' ratio were strongly positively associated with CAV. In our population, left ventricular global longitudinal strain (GLS), layer-specific GLS and the endocardial-epicardial LS gradient, E wave DT and E/e' ratio were the best independent non-invasive predictors of CAV.
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Affiliation(s)
- C Sciaccaluga
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy.
| | - G E Mandoli
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - N Sisti
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - M B Natali
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - A Ibrahim
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - D Menci
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - A D'Errico
- Department of Internal Medicine, University of Siena, Siena, Italy
| | - G Donati
- Department of Internal Medicine, University of Siena, Siena, Italy
| | - G Benfari
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - S Valente
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - S Bernazzali
- Department of Cardiac Surgery, University Hospital of Siena, Siena, Italy
| | - M Maccherini
- Department of Cardiac Surgery, University Hospital of Siena, Siena, Italy
| | - S Mondillo
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - M Cameli
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
| | - M Focardi
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy
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Citro R, Iesu I, Picano E. The many applications of stress echocardiography in heart transplantation. Int J Cardiol 2019; 296:127-128. [PMID: 31474413 DOI: 10.1016/j.ijcard.2019.08.035] [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: 08/01/2019] [Accepted: 08/14/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Rodolfo Citro
- Cardio-Thoracic-Vascular Department, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy.
| | - Ivana Iesu
- Cardiology Department, University Federico II, Naples, Italy
| | - Eugenio Picano
- CNR, Institute of Clinical Physiology, Biomedicine Department, Pisa, Italy
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Elkaryoni A, Abu-Sheasha G, Altibi AM, Hassan A, Ellakany K, Nanda NC. Diagnostic accuracy of dobutamine stress echocardiography in the detection of cardiac allograft vasculopathy in heart transplant recipients: A systematic review and meta-analysis study. Echocardiography 2019; 36:528-536. [PMID: 30726558 DOI: 10.1111/echo.14268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 11/28/2018] [Accepted: 01/06/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Dobutamine stress echocardiography (DSE) is a well-established imaging modality used to screen patients with mild-to-moderate risk for coronary artery disease. In heart transplantation recipients, cardiac allograft vasculopathy (CAV) is a common and lethal complication. The use of DSE to detect CAV showed promising results initially, but later studies showed limitation in its use to detect CAV. It is unclear if this cohort of patients derives benefit from DSE. METHODS We searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and Scopus from inception through March 2018 for studies examining the accuracy of DSE in correlation to coronary angiography (CA) or intravascular ultrasound (IVUS) to detect CAV. Original studies comparing the ability of DSE to detect CAV in comparison with CA or IVUS were included. Relevant data were extracted and hierarchical summary receiver operating characteristic analysis was conducted to test the overall diagnostic accuracy of DSE for patients with CAV. RESULTS Eleven studies (749 participants) met the inclusion criteria. The sensitivity of DSE varied from 1.7% to 93.8%, and specificity, from 54.8% to 98.8%. Pooled sensitivity was 60.2% (95% confidence interval (CI), 33.0%-82.3%) and specificity 85.7% (95% CI, 73.8%-92.7%). DSE had an overall diagnostic odds ratio (OR) of 9.1 (95% CI, 4.6-17.8), positive likelihood ratio (LR+) of 4.1 (95% CI, 2.8-6.1), negative likelihood ratio (LR-) of 0.47 (95% CI: 0.23-0.73), and area under curve (AUC) of 0.73 (95% CI, 0.72-0.75). Heterogeneity among studies was not statistically significant (τ2 = 0.32, Cochran's Q = 9.5, P = 0.483). CONCLUSION Dobutamine stress echocardiography has a limited sensitivity to detect early CAV but its specificity is much higher. There remains a need for an alternative noninvasive modality which will have both high sensitivity and high specificity for detecting CAV.
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Affiliation(s)
- Ahmed Elkaryoni
- Division of Internal Medicine, University of Missouri Kansas City, Kansas City, Missouri
| | - Ghada Abu-Sheasha
- Division of Biomedical Statistics and Medical Informatics, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Ahmed M Altibi
- Division of Internal Medicine, Henry Ford Allegiance Health, Jackson, Michigan
| | - Adil Hassan
- Division of Internal Medicine, University of Missouri Kansas City, Kansas City, Missouri
| | - Karim Ellakany
- Division of Cardiovascular Disease, University of Alexandria School of medicine, Alexandria, Egypt
| | - Navin C Nanda
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
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Olymbios M, Kwiecinski J, Berman DS, Kobashigawa JA. Imaging in Heart Transplant Patients. JACC Cardiovasc Imaging 2018; 11:1514-1530. [DOI: 10.1016/j.jcmg.2018.06.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/30/2018] [Accepted: 06/07/2018] [Indexed: 01/06/2023]
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Abstract
PURPOSE OF REVIEW Cardiac allograft vasculopathy (CAV) is a major limitation to long-term survival after heart transplantation. Innovative new techniques to diagnose CAV have been applied to detect disease. This review will examine the current diagnostic and treatment options available to clinicians for CAV. RECENT FINDINGS Diagnostic modalities addressing the pathophysiology underlying CAV (arterial wall thickening and decreased coronary blood flow) improve diagnostic sensitivity when compared to traditional (angiography and dobutamine stress echocardiography) techniques. SUMMARY Limited options are available to prevent and treat CAV; however, progress has been made in making an earlier and more accurate diagnosis. Future research is needed to identify the optimal time to modify immunosuppression and investigate novel treatments for CAV.
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Post-transplant surveillance for acute rejection and allograft vasculopathy by echocardiography: Usefulness of myocardial velocity and deformation imaging. J Heart Lung Transplant 2017; 36:117-131. [DOI: 10.1016/j.healun.2016.09.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 09/27/2016] [Accepted: 09/28/2016] [Indexed: 11/18/2022] Open
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Badano LP, Miglioranza MH, Edvardsen T, Colafranceschi AS, Muraru D, Bacal F, Nieman K, Zoppellaro G, Marcondes Braga FG, Binder T, Habib G, Lancellotti P, Sicari R, Cosyns B, Donal E, Lombardi M, Sarvari S. European Association of Cardiovascular Imaging/Cardiovascular Imaging Department of the Brazilian Society of Cardiology recommendations for the use of cardiac imaging to assess and follow patients after heart transplantation. ACTA ACUST UNITED AC 2015; 16:919-48. [DOI: 10.1093/ehjci/jev139] [Citation(s) in RCA: 141] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/02/2015] [Indexed: 01/10/2023]
Affiliation(s)
- Luigi P. Badano
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, School of Medicine, Via Giustiniani 2, 35128 Padova, Italy
| | | | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | | | - Denisa Muraru
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, School of Medicine, Via Giustiniani 2, 35128 Padova, Italy
| | - Fernando Bacal
- Heart Transplant Department, Heart Institute, University of São Paulo, São Paulo, Brazil
| | - Koen Nieman
- Intensive Cardiac Care Unit and Cardiac CT Research, Erasmus MC, Rotterdam, The Netherlands
| | - Giacomo Zoppellaro
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, School of Medicine, Via Giustiniani 2, 35128 Padova, Italy
| | | | - Thomas Binder
- Department of Cardiology, University of Vienna, Wien, Austria
| | - Gilbert Habib
- Service de Cardiologie, Hôpital La Timone, Marseille, France
| | - Patrizio Lancellotti
- Department of Cardiology, Heart Valve Clinic, University of Liège, GIGA Cardiovascular Sciences, CHU Sart Tilman, Liège, Belgium
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Miller CA, Chowdhary S, Ray SG, Sarma J, Williams SG, Yonan N, Mittal TK, Schmitt M. Role of Noninvasive Imaging in the Diagnosis of Cardiac Allograft Vasculopathy. Circ Cardiovasc Imaging 2011; 4:583-93. [PMID: 21934085 DOI: 10.1161/circimaging.110.961425] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Christopher A. Miller
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Saqib Chowdhary
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Simon G. Ray
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Jaydeep Sarma
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Simon G. Williams
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Nizar Yonan
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Tarun K. Mittal
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Matthias Schmitt
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
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Estep JD, Shah DJ, Nagueh SF, Mahmarian JJ, Torre-Amione G, Zoghbi WA. The role of multimodality cardiac imaging in the transplanted heart. JACC Cardiovasc Imaging 2009; 2:1126-40. [PMID: 19761994 DOI: 10.1016/j.jcmg.2009.06.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Revised: 06/19/2009] [Accepted: 06/24/2009] [Indexed: 10/20/2022]
Abstract
Heart transplantation (HT) is an established life-saving treatment option for patients with end-stage heart failure. Despite many advances in the field, the development of acute cellular rejection (ACR) and cardiac allograft vasculopathy (CAV) represent significant causes of 1- and 5-year morbidity and mortality, respectively. The search for noninvasive techniques to assess cardiac allograft function and detect treatable ACR and CAV remains a priority objective for heart transplant professionals. In this review we will: 1) highlight the clinical significance of ACR and CAV in adult cardiac transplant recipients and 2) discuss how different noninvasive imaging modalities (echocardiography, cardiac computed tomography, myocardial perfusion imaging, and cardiac magnetic resonance) have been used in the evaluation of these clinical challenges after HT.
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Affiliation(s)
- Jerry D Estep
- Department of Cardiology, Section of Heart Failure and Heart Transplantation, and Cardiovascular Imaging Institute, Methodist DeBakey Heart and Vascular Center, Houston, Texas 77030, USA.
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Abstract
Despite the widespread use of echocardiography in the cardiac allograft recipient, the clinical usefulness of this practice is not well defined. In this article, the authors review the spectrum of echocardiographic findings in the adult heart transplant patient. Appreciation of typical alterations from "normal" allows the transplant physician to identify clinically significant changes and to avoid unnecessary invasive procedures based on misinterpretation of these differences. Though abnormalities of systolic and diastolic function correlate with episodes of acute rejection, the primary diagnostic usefulness of echocardiography in acute rejection is guiding the endomyocardial biopsy. Additionally, echocardiography has found a role as a supplement to invasive angiography in the diagnosis of cardiac allograft vasculopathy.
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Affiliation(s)
- Eric M Thorn
- University of Maryland School of Medicine, Baltimore, MD 21201-1595, USA
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Abstract
PURPOSE OF REVIEW Graft coronary artery disease is the leading cardiac cause of death in patients who have undergone cardiac transplantation. Due to denervation, classic symptoms of angina are not reliable. Many transplant centers have a protocol of routine annual surveillance cardiac angiography because treatment options are limited, especially with advanced disease. Angiography is an assessment of the arterial lumen, however, and can miss nonfocal disease. This paper reviews invasive and noninvasive diagnostic tools for graft coronary artery disease. Intravascular ultrasound is the most sensitive, but the cost and lack of widespread expertise make it unpopular. Noninvasive techniques have been studied. An ideal test would be sufficiently sensitive to detect disease and allow for prognostic information. Dobutamine echocardiography is the most sensitive noninvasive test but can have a high false-positive rate. It is also not universally available. Exercise nuclear imaging is specific and can be used as a confirmatory test in patients with positive dobutamine echocardiograms. RECENT FINDINGS Computed tomographic imaging and cardiac magnetic resonance imaging are exciting new modalities but require further study. SUMMARY There is no test sensitive and specific enough yet that can be confidently used to replace coronary angiography.
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Affiliation(s)
- Malek Kass
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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14
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Abstract
Cardiac transplantation has emerged as a valuable therapy for various end-stage cardiac disorders. Cardiac allograft vasculopathy (CAV), an unusually accelerated and diffuse form of obliterative coronary arteriosclerosis, determines long-term function of the transplanted heart. Cardiac allograft vasculopathy is a complicated interplay between immunologic and nonimmunologic factors resulting in repetitive vascular injury and a localized sustained inflammatory response. Dyslipidemia, oxidant stress, immunosuppressive drugs, and viral infection appear to be important contributors to disease development. Endothelial dysfunction is an early feature of CAV and progresses over time after transplantation. Early identification of CAV is essential if long-term prognosis is to be improved. Annual coronary angiography is performed for diagnostic and surveillance purposes. Intravascular ultrasound is a more sensitive diagnostic tool for early disease stages and has revealed that progressive luminal narrowing in CAV is in part due to negative vascular remodeling. Because of the diffuse nature of CAV, percutaneous and surgical revascularization procedures have a limited role. Prevention of CAV progression is a primary therapeutic goal.
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Affiliation(s)
- D Behrendt
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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15
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Abstract
BACKGROUND Transplant-associated arteriosclerosis is the major limitation to long-term survival in the cardiac transplant recipient, and annual surveillance angiography is used in many centers to monitor its progression. Noninvasive methods would be preferable because angiography is invasive, costly, and insensitive; however, the reliability of such methods has been questioned. METHODS All publications relating to the assessment of the cardiac allograft by noninvasive testing were identified through MEDLINE and a review of references from the published literature on transplant-associated arteriosclerosis. RESULTS Resting and stress ECG, radionuclide scintigraphy, echocardiography, and positron emission tomography have all been used in cardiac transplant recipients with variable results. Most techniques are insensitive, but this limitation may be improved with pharmacologic stress imaging like dobutamine echocardiography. Although insensitive, some methods have good specificity (i.e., radionuclide scintigraphy). The noninvasive measurement of absolute coronary blood flow is promising as a specific and sensitive technique but is limited by availability and cost. CONCLUSIONS In general, noninvasive techniques to assess transplant-associated coronary arteriosclerosis are limited by variable sensitivity and specificity. However, certain methods, such as dobutamine echocardiography and radionuclide scintigraphy, can provide important adjunctive physiologic information to angiography. Such techniques can therefore help to guide the care and treatment of the cardiac transplant recipient with allograft coronary arteriosclerosis.
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Affiliation(s)
- J C Fang
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass 02115, USA
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Gotsman MS, Mosseri M, Rozenman Y, Admon D, Lotan C, Nassar H. Atherosclerosis studies by intracoronary ultrasound. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 1997; 430:197-212. [PMID: 9330730 DOI: 10.1007/978-1-4615-5959-7_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Intravascular ultrasound (IVUS) is a new technique of tomographic visualization of the coronary arteries: its lumen, wall and pathology. Three dimensional (3D) reconstruction shows the tubular structure of the arterial wall and its pathology. IVUS has many advantages over coronary angiography: it has better resolution and shows many hidden lesions. IVUS has helped uncover the underlying mechanisms of percutaneous transluminal coronary angioplasty (PTCA), restenosis, the use and value of other interventional techniques such as directional coronary atherectomy (DCA), rotational atherectomy and stent implantation, and has great value in planning complex interventional procedures. The new American Heart Association (AHA) classification of coronary atherosclerosis pathology can be demonstrated by IVUS. IVUS is sensitive for studies of atheroma regression and progression and shows the coronary artery lesions after cardiac transplantation.
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Affiliation(s)
- M S Gotsman
- Cardiology Department, Hadassah University Hospital, Jerusalem, Israel
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17
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Abstract
Cardiac allograft vasculopathy (CAV) remains a troublesome long-term complication of heart transplantation. It is manifested by a unique and unusually accelerated form of coronary disease affecting both intramural and epicardial coronary arteries and veins.CAV is characterized by vascular injury induced by a variety of noxious stimuli, including the immune system response to the allograft, ischemia-reperfusion injury, viral infection, immunosuppressive drugs, and classic risk factors such as hyperlipidemia, insulin resistance, and hypertension. The obstructive vascular lesions are thought to progress through repetitive endothelial injury followed by repair response. The role of major histocompatibility complex donor-recipient differences in the pathogenesis of CAV has not yet been completely elucidated. Intracoronary ultrasound studies reveal a dual morphology with donor-transmitted or de novo focal, noncircumferential plaques in proximal segments and/or a diffuse, concentric pattern observed in distal segments. A lack of correlation between microvascular and epicardial vessel disease suggests discordant manifestations and progression of CAV. Apoptosis and loss of functional vascular remodeling have to be considered as important mediators of clinically relevant CAV. Strategies for blocking T-cell costimulation and expression of adhesion molecules may help prevent chronic rejection in clinical transplantation. 3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors and antiproliferative drugs may slow progression of CAV by various effects. Methods to augment endogenous nitric oxide bioavailability as well as newer immunosuppressive regimens may be protective. Balloon angioplasty has a limited role in the treatment of focal lesions. Experiences with coronary stenting, coronary artery bypass grafting, and transmyocardial laser revascularization are limited. Retransplantation has a worse outcome than initial transplantation.
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Affiliation(s)
- M Weis
- Medizinische Klinik und Poliklinik I, Klinikum Grosshadern, University of Munich, Germany.
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