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Exercise echocardiography, angiography, and intracoronary ultrasound after cardiac transplantation
J M Cohn1, R L Wilensky, J A O'Donnell
1Krannert Institute of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.
Insights
Exercise echocardiography is insensitive for detecting transplant coronary artery disease. However, angiography showing luminal irregularities may predict significant intimal thickening after cardiac transplantation.
Area of Science:
- Cardiology
- Transplant Medicine
- Medical Imaging
Background:
- Cardiac transplantation is a life-saving procedure for end-stage heart failure.
- Coronary artery disease (cardiac allograft vasculopathy) is a major long-term complication after heart transplantation.
- Early detection and monitoring of cardiac allograft vasculopathy are crucial for patient survival.
Purpose of the Study:
- To evaluate the effectiveness of exercise echocardiography and angiography in detecting coronary artery disease after cardiac transplantation.
- To compare the diagnostic performance of these imaging modalities with intracoronary ultrasound (ICUS).
Main Methods:
- Fifty-one heart transplant recipients underwent serial exercise echocardiography, angiography, and ICUS.
- Coronary artery disease was assessed by angiography (stenosis or luminal irregularities) and ICUS (intimal thickening).
- Exercise echocardiography was used to detect inducible wall motion abnormalities.
Main Results:
- Angiography revealed coronary artery disease in 26 patients (51%), while ICUS showed intimal thickening in all 51 patients.
- Intimal thickening progressed in 12 of 25 patients with serial evaluations.
- Exercise echocardiography had low sensitivity (15%) for detecting significant intimal thickening (class III-IV), but angiography showed higher sensitivity (64%) and specificity (76%).
Conclusions:
- Exercise echocardiography is an insensitive tool for predicting transplant-mediated coronary artery disease.
- Angiographic findings of luminal irregularities may predict the presence of significant intimal thickening (Stanford grade III-IV).
- ICUS is more sensitive in detecting intimal thickening compared to angiography and exercise echocardiography.
Abstract:
Fifty-one consecutive patients underwent exercise echocardiography, angiography, and intracoronary ultrasound (ICUS) 2.5 years (range from 1 to 6) after cardiac transplantation. The average age of the donor was 29 years (range 13 to 50), and the average age of the recipient was 49 +/- 12 years. In total, 78 studies were performed, as 25 patients had >1 annual evaluation and 2 patients had 3 consecutive annual evaluations. Of the 78 angiographic studies, 40 (26 patients) had evidence of coronary artery disease, defined as a focal stenosis (>20%, n=4) or luminal irregularities (n=36). However, by ICUS all 51 patients had intimal thickening at some point, with 34 patients possessing diffuse disease and 17 focal intimal thickening only. Of the 25 serial studies, 12 progressed by at least 1 Stanford class. The sensitivity of angiography for determination of class III to IV intimal thickening was 64% and the specificity was 76%. On exercise echocardiography, 6 examinations revealed resting wall motions abnormalities, whereas 6 had inducible wall motion abnormalities with exercise. The sensitivity of exercise echocardiography to determine class III to IV intimal thickening was 15%, and the specificity was 85%. In conclusion, exercise echocardiography is an insensitive method for predicting transplant-mediated coronary artery disease, whereas luminal irregularities on angiography may predict the presence of Stanford grade III to IV intimal thickening.