Comparison of Dual Source Computed Tomography Versus Intravascular Ultrasound for Evaluation of Coronary Arteries at Least One Year After Cardiac Transplantation

doi:10.1016/j.amjcard.2009.06.060

The American Journal of Cardiology

Volume 104, Issue 10, 15 November 2009, Pages 1351-1356

https://doi.org/10.1016/j.amjcard.2009.06.060 Get rights and content

This study evaluated the ability of dual-source computed tomography (DSCT) to detect coronary allograft vasculopathy (CAV) in heart transplant recipients using intravascular ultrasound (IVUS) as the standard of reference. Thirty patients with heart transplants (81% men, mean age 40 years) underwent DSCT (330-ms gantry rotation, 2 × 64 × 0.6-mm collimation, 60- to 80-ml contrast agent, no additional β blockers) before invasive coronary angiography including IVUS of 1 vessel. Detection of CAV by DSCT was qualitatively defined as the presence of any coronary plaque. Mean heart rate during dual-source computed tomographic scanning was 80 ± 14 beats/min. Four hundred fifty-nine segments with a vessel caliber ≥1.5 mm according to quantitative coronary angiography were evaluated in 30 patients. Of these, 96% were considered to have excellent or good image quality. IVUS detected CAV in 17 of 30 patients (57%) and in 41 of 110 coronary segments (37%). Compared to IVUS, sensitivity, specificity, positive and negative predictive values for the detection of CAV by DSCT were 85%, 84%, 76%, and 91%, respectively. In conclusion, DSCT permits the investigation of transplant recipients concerning the presence of CAV with good image quality and high diagnostic accuracy.

Section snippets

Methods

Consecutive patients with previous orthotopic heart transplantation and scheduled for routine follow-up invasive coronary angiography were prospectively enrolled to undergo DSCT within 24 hours before invasive coronary angiography including IVUS of 1 vessel. Patients were eligible if they were ≥18 years of age, ≥12 months after cardiac transplantation, and in stable clinical condition. Patients with atrial fibrillation, contraindications to iodinated contrast agents, and serum creatinine values

Results

Forty-one patients were screened for study participation. Eleven subjects (27%) were excluded from computed tomographic assessment due to serum creatinine values >1.4 mg/dl. The remaining 30 patients (81% men, mean age 40 years, range 18 to 69) underwent DSCT at a mean interval of 34 months (range 12 to 74) after heart transplantation. Mean body mass index was 26 ± 8 kg/m². Mean heart rate during scanning was 80 ± 15 beats/min (range 60 to 101). Eleven patients had a heart rate <75 beats/min

Discussion

CAV is the most important cause of long-term mortality in heart transplant recipients, and it is difficult to detect by coronary angiography or noninvasive studies. IVUS allows early detection and monitoring of CAV. As a consequence, medical treatment such as aggressive lipid lowering may be initiated in the early stages of the disease. However, IVUS is not widely used because of its invasive nature with associated complications, high costs, and inconvenience to the patient. This study is, to

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Cited by (46)

Non-invasive Imaging in the Evaluation of Cardiac Allograft Vasculopathy in Heart Transplantation: A Systematic Review
2022, Current Problems in Cardiology
Cardiac allograft vasculopathy (CAV) is the leading cause of long-term graft dysfunction in patients with heart transplantation and is linked with significant morbidity and mortality. Currently, the gold standard for diagnosing CAV is coronary imaging with intravascular ultrasound during traditional invasive coronary angiography. Invasive imaging, however, carries increased procedural risk and expense to patients in addition to requiring an experienced interventionalist. With the improvements in non-invasive cardiac imaging modalities such as transthoracic echocardiography, computed tomography, magnetic resonance imaging and positron emission tomography, an alternative non-invasive imaging approach for the early detection of CAV may be feasible. In this systematic review, we explored the literature to investigate the utility of non-invasive imaging in diagnosis of CAV in >3000 patients across 49 studies. We also discuss the strengths and weaknesses for each imaging modality. Overall, all 4 imaging modalities show good to excellent accuracy for identifying CAV with significant variations across studies. Majority of the studies compared non-invasive imaging with invasive coronary angiography without intravascular imaging. In summary, non-invasive imaging modalities offer an alternative approach to invasive coronary imaging for CAV. Future studies should investigate longitudinal non-invasive protocols in low-risk patients after heart transplantation.
Evaluation of cardiac allograft vasculopathy by positron emission tomography
2021, Journal of Nuclear Cardiology
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.
Dobutamine stress echocardiography during follow-up surveillance in heart transplant patients: Diagnostic accuracy and predictors of outcomes
2015, Journal of Heart and Lung Transplantation
Citation Excerpt :
Tests like contrast-enhanced coronary computed tomographic angiography (CCTA) have the potential to detect early vessel wall changes of CAV, potentially offering an attractive alternative, especially in light of our findings showing that the extent of CAV has incremental prognostic value. Indeed, in previous studies, the sensitivity, specificity, PPV and NPV for CCTA to detect >50% angiographic stenosis was 71% to 93%, 80% to 99%, 48% to 91% and 98% to 100%, respectively.31–35 When compared with IVUS (intimal thickness >0.5 mm), the NPV of CCTA to detect early-stage CAV was relatively low (77% to 98%).31,32,36
Cardiac allograft vasculopathy (CAV), a major cause of graft failure and mortality at >3 years after orthotopic heart transplantation (OHT), is commonly evaluated using dobutamine stress echocardiography (DSE). We sought to study: (a) the incidence of positive results and diagnostic accuracy of DSE; and (b) the predictors of adverse outcomes in OHT patients.
We studied 497 consecutive patients (63 ± 10 years, 78% men) with OHT who had undergone DSE as part of routine surveillance at our center between 1998 and 2013. Every DSE and coronary angiogram performed during follow-up was reviewed. CAV was regraded according to the 2010 recommendations of the International Society for Heart and Lung Transplantation. Composite events (death, coronary revascularization, myocardial infarction and retransplantation) were recorded.
There were 1,243 DSE studies performed during a median of 8.7 (6.2 to 11.9) years after transplantation. Only 22 studies (1.8%) were positive, 978 (78.7%) were negative and 243 (19.5%) were non-diagnostic (sub-maximal heart rate response) for ischemia. Among 497 patients, only 20 (4%) had at least one positive DSE study. There were 310 diagnostic DSEs with coronary angiograms performed within 1 year of one another other. In this subgroup, the sensitivity, specificity, positive predictive value and negative predictive value of DSE were 7%, 98%, 82% and 41%, respectively, to detect any CAV, and 28%, 98%, 71% and 89% to detect CAV Grades 2 or 3, respectively. There were no deaths during DSE. At 5.6 ± 3.6 years after DSE, there were 201 (40%) events. Degree of CAV (and not DSE-based ischemia, p = 0.3) independently predicted outcomes (p < 0.001).
The incidence of a positive result is very low in OHT patients undergoing surveillance DSE. DSE is insufficiently sensitive for detection of early CAV. Degree of CAV and not DSE-based ischemia independently predicted outcomes.
Imaging for coronary allograft vasculopathy in children and adolescents
2014, Progress in Pediatric Cardiology
Citation Excerpt :
In heart transplant patients it appears at least as good as angiography in identifying coronary stenosis with high sensitivity and specificity [74]. It may correlate with IVUS-determined intimal thickness > 0.5 mm, with variable but generally lower sensitivity [75–78]. It has been used in pediatric transplant recipients [79].
Cardiomyopathy is the main indication for pediatric heart transplantation. The major limitation on the long term survival after transplantation is coronary allograft vasculopathy (CAV). The usual method of diagnosis for CAV is coronary angiography. This is invasive and only detects late disease. Early disease may be detected with intravascular ultrasound or optical coherence tomography. Physiological assessment can be with fractional flow reserve or coronary flow reserve. The latter is more accurate in CAV. These tests are all invasive. Non-invasive testing with echocardiography has been used, particularly with stress testing but this can be difficult in children and international standards are not agreed. Non-invasive testing with Single Photon Emission Tomography Computed Tomography and Positron Emission Tomography have not been widely adopted in pediatrics but Computerised Tomography is becoming more common and can rival angiography. However all of these techniques use ionising radiation. Magnetic resonance imaging may be the future of pediatric coronary imaging as it is non-invasive, does not use ionising radiation, or nephrotoxic contrast, can image small and large vessels and can give accurate functional assessment.
Coronary computed tomography angiography: Is it time to replace the conventional coronary angiogram in heart transplant patients?
2014, Journal of the American College of Cardiology
Coronary computed tomography angiography for the detection of cardiac allograft vasculopathy: A meta-analysis of prospective trials
2014, Journal of the American College of Cardiology
Citation Excerpt :
Of the 13 studies, 8 studies analyzing 410 patients (mean age 49 ± 7.6 years; 81% male) and 5,949 coronary segments evaluated CAV using 64-slice CCTA (7,8,10,25–29). Seven studies compared 64-slice CCTA with CCAG and 2 studies compared 64-slice CCTA with IVUS (7,10). Six studies analyzing 205 patients (mean age 50 ± 8.0 years; 83% male) and 3,532 coronary segments evaluated CAV using 16-slice CCTA, with all of them using CCAG for comparison and 2 of them also using IVUS for comparison (Table 1) (6,9,26,30–32).
This study aimed to evaluate the diagnostic accuracy of coronary computed tomography angiography (CCTA) for detecting cardiac allograft vasculopathy (CAV) in comparison with conventional coronary angiography (CCAG) alone or with intravascular ultrasound (IVUS).
CAV limits long-term survival after heart transplantation, and screening for CAV is performed on annual basis. CCTA is currently not recommended for CAV screening due to the limited accuracy reported by early studies. Technological advances, however, might have resulted in improved test performance and might justify re-evaluation of this recommendation.
A systematic review of Medline, Cochrane, and Embase for all prospective trials assessing CAV using CCTA was performed using a standard approach for meta-analysis for diagnostic test and a bivariate analysis.
Thirteen studies evaluating 615 patients (mean age 52 years, 83% male) and 9,481 segments fulfilled inclusion criteria. Patient-based analyses comparing CCTA versus CCAG for the detection of any CAV (> luminal irregularities) and significant CAV (stenosis ≥50%), showed mean weighted sensitivities of 97% and 94%, specificities of 81% and 92%, a negative predictive value (NPV) of 97% and 99%, a positive predictive value (PPV) of 78% and 67%, and diagnostic accuracies of 88% and 94%, respectively. There was a strong trend toward improved sensitivity (97% vs. 91%, p = 0.06) and NPV (99% vs. 97%, p = 0.06) to detect significant CAV with 64-slice compared with 16-slice CCTA. A patient-based analysis of 64-slice CCTA versus IVUS showed a mean weighted sensitivity and specificity of 81% and 75% to detect CAV (intimal thickening >0.5 mm), whereas the PPV and NPV were 93% and 50%, respectively.
CCTA using currently available technology is a reliable noninvasive imaging alternative to coronary angiography with an excellent sensitivity, specificity, and NPV for the detection of CAV.

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: This work was supported by Grant 01 EV 0708 from Bundesministerium für Bildung und Forschung, Berlin, Germany.

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Coronary artery diseaseComparison of Dual Source Computed Tomography Versus Intravascular Ultrasound for Evaluation of Coronary Arteries at Least One Year After Cardiac Transplantation

Section snippets

Methods

Results

Discussion

J Heart Lung Transplant

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Atherosclerosis

Am J Cardiol

J Am Coll Cardiol

Eur J Radiol

J Cardiovasc Comput Tomogr

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Coronary artery disease
Comparison of Dual Source Computed Tomography Versus Intravascular Ultrasound for Evaluation of Coronary Arteries at Least One Year After Cardiac Transplantation