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Surgical Swine Model of Chronic Cardiac Ischemia Treated by Off-Pump Coronary Artery Bypass Graft Surgery
Published on: March 27, 2018
Diagnosis of graft coronary artery disease
Malek Kass1, Rebecca Allan, Haissam Haddad
1Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
Insights
Diagnosing graft coronary artery disease in heart transplant patients is challenging. Current noninvasive tests lack the sensitivity and specificity to replace traditional coronary angiography for surveillance.
Area of Science:
- Cardiology
- Transplantation Medicine
- Diagnostic Imaging
Background:
- Graft coronary artery disease (CAD) is the primary cause of death post-cardiac transplant.
- Denervation in transplanted hearts limits the reliability of classic angina symptoms for diagnosis.
- Routine annual cardiac angiography is common but may miss non-focal disease.
Purpose of the Study:
- To review invasive and noninvasive diagnostic tools for graft CAD.
- To evaluate the sensitivity and specificity of various diagnostic modalities.
- To identify an ideal diagnostic test for graft CAD surveillance.
Main Methods:
- Review of invasive techniques, including intravascular ultrasound.
- Assessment of noninvasive methods like dobutamine echocardiography and exercise nuclear imaging.
- Consideration of emerging modalities such as computed tomographic and cardiac magnetic resonance imaging.
Main Results:
- Intravascular ultrasound is highly sensitive but limited by cost and availability.
- Dobutamine echocardiography shows high sensitivity but a significant false-positive rate.
- Exercise nuclear imaging offers specificity and can be a confirmatory test.
Conclusions:
- No current diagnostic test is sufficiently sensitive and specific to replace coronary angiography for graft CAD surveillance.
- Further research is needed for advanced imaging techniques like CT and MRI.
- Developing a reliable, noninvasive test remains a critical unmet need in heart transplantation.
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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