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Multiparametric cardiovascular magnetic resonance assessment of cardiac allograft vasculopathy
Christopher A Miller1, Jaydeep Sarma2, Josephine H Naish3
1North West Heart Centre and Transplant Centre, University Hospital of South Manchester, Wythenshawe Hospital, Manchester, United Kingdom; Centre for Imaging Sciences and Biomedical Imaging Institute, University of Manchester, Manchester, United Kingdom; Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom.
Insights
Multiparametric cardiovascular magnetic resonance (CMR) accurately detects cardiac allograft vasculopathy (CAV), including epicardial and microvascular disease. This noninvasive technique outperforms traditional coronary angiography for CAV surveillance in heart transplant recipients.
Area of Science:
- Cardiovascular Imaging
- Transplant Cardiology
- Cardiac Allograft Vasculopathy
Background:
- Cardiac allograft vasculopathy (CAV) significantly impacts long-term survival in heart transplant recipients.
- Coronary angiography is the current standard for CAV surveillance, with routine annual or biannual monitoring recommended.
Purpose of the Study:
- To evaluate the diagnostic performance of multiparametric cardiovascular magnetic resonance (CMR) for detecting CAV.
- To compare the efficacy of CMR against coronary angiography using invasive epicardial and microvascular assessments as reference standards.
Main Methods:
- Prospective study of heart transplant recipients undergoing surveillance angiography.
- Invasive assessments included coronary intravascular ultrasound, fractional flow reserve, and index of microcirculatory resistance.
- Multiparametric CMR, including myocardial blood flow quantification, was performed within one month of invasive procedures.
Main Results:
- CMR-derived myocardial perfusion reserve was the sole independent predictor of both epicardial and microvascular CAV.
- CMR significantly outperformed angiography in detecting moderate and severe CAV.
- Area under the curve for CMR was 0.89 for moderate CAV and 0.88 for severe CAV, compared to 0.59 and 0.67 for angiography, respectively.
Conclusions:
- Noninvasive CMR-based absolute myocardial blood flow assessment offers superior accuracy for detecting CAV compared to invasive coronary angiography.
- Multiparametric CMR can effectively identify both epicardial and microvascular components of CAV.
- CMR represents a more accurate diagnostic tool for CAV surveillance in heart transplant recipients.
Objectives:
This study sought to evaluate the diagnostic performance of multiparametric cardiovascular magnetic resonance (CMR) for detecting cardiac allograft vasculopathy (CAV) using contemporary invasive epicardial artery and microvascular assessment techniques as reference standards, and to compare the performance of CMR with that of angiography.
Background:
CAV continues to limit the long-term survival of heart transplant recipients. Coronary angiography has a Class I recommendation for CAV surveillance and annual or biannual surveillance angiography is performed routinely in most centers.
Methods:
All transplant recipients referred for surveillance angiography at a single UK center over a 2-year period were prospectively screened for study eligibility. Patients prospectively underwent coronary angiography followed by coronary intravascular ultrasound, fractional flow reserve, and index of microcirculatory resistance. Within 1 month, patients underwent multiparametric CMR, including assessment of regional and global ventricular function, absolute myocardial blood flow quantification, and myocardial tissue characterization. In addition, 10 healthy volunteers underwent CMR.
Results:
Forty-eight patients were recruited, median 7.1 years (interquartile range: 4.6 to 10.3 years) since transplantation. The CMR myocardial perfusion reserve was the only independent predictor of both epicardial (β = -0.57, p < 0.001) and microvascular disease (β = -0.60, p < 0.001) on stepwise multivariable regression. The CMR myocardial perfusion reserve significantly outperformed angiography for detecting moderate CAV (area under the curve, 0.89 [95% confidence interval (CI): 0.79 to 1.00] vs. 0.59 [95% CI: 0.42 to 0.77], p = 0.01) and severe CAV (area under the curve, 0.88 [95% CI: 0.78 to 0.98] vs. 0.67 [95% CI: 0.52 to 0.82], p = 0.05).
Conclusions:
CAV, including epicardial and microvascular components, can be detected more accurately using noninvasive CMR-based absolute myocardial blood flow assessment than with invasive coronary angiography, the current clinical surveillance technique.
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