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Zhao M, Xing E, Zhao J, Chen F, Chen M, Lu A, Pan C, Bai L, Zhang J, Wa Y, Wang T, Zhao Y, Niu X, Bai M. Myocardial flow reserve derived from D-SPECT for evaluating non-culprit ischemic lesions in STEMI patients: comparison with quantitative flow ratio. Eur J Nucl Med Mol Imaging 2025:10.1007/s00259-025-07223-0. [PMID: 40237794 DOI: 10.1007/s00259-025-07223-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2024] [Accepted: 03/15/2025] [Indexed: 04/18/2025]
Abstract
OBJECTIVES This study sought to elucidate the diagnostic performance and concordance between myocardial flow reserve (MFR) derived from dynamic single-photon emission computed tomography (D-SPECT) and quantitative flow ratio (QFR) in evaluating non-culprit ischemic lesions following ST-elevation myocardial infarction (STEMI). Additionally, the study investigated the integration of MFR with angiographic microvascular resistance (AMR) derived from coronary angiography to determine its utility in screening and stratifying non-culprit ischemic lesions. BACKGROUND The diagnostic performance and agreement between MFR and QFR in evaluating non-culprit ischemic lesions in STEMI patients with multivessel disease are unknown. METHODS This research encompassed a cohort of 106 STEMI patients with at least 1 intermediate non-culprit ischemic lesion, characterized by 40-80% diameter stenosis. After undergoing percutaneous coronary intervention, patients were evaluated using QFR and, approximately five days later, underwent D-SPECT to assess myocardial blood flow (MBF) and MFR. MFR was evaluated against QFR as a reference for diagnostic performance and agreement, including sensitivity analysis in vessels with normal microvascular function. Furthermore, MFR, combined with AMR, effectively screened and stratified non-culprit ischemic lesions. Non-culprit ischemic lesions were defined by QFR ≤ 0.80 and normal microvascular function by AMR < 255 mmHg*s/m. RESULTS Among non-culprit lesions, MFR predicted a QFR ≤ 0.80 with a sensitivity of 85%, specificity of 86%, and accuracy of 86%. The positive predictive value was 56%, and the negative predictive value was 96%. The MFR cut-off was 1.93, with an area under the receiver operating characteristic curve of 0.90 (95% CI: 0.84 to 0.94). MFR showed similar diagnostic performance in patients with normal microcirculation. Moreover, low MFR with normal AMR indicated non-culprit ischemic lesions caused solely by epicardial narrowing, while low MFR with abnormal AMR indicated ischemic lesions complicated by microvascular dysfunction. CONCLUSION MFR derived from D-SPECT exhibits good diagnostic performance and moderate agreement in identifying non-culprit ischemic lesions in patients with STEMI. Combining AMR with MFR effectively screens and stratifies non-culprit ischemic lesions. TRIAL REGISTRATION ChiCTR.org.cn. ChiCTR2200059934. Registered 13 May 2022.
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Affiliation(s)
- Maomao Zhao
- Department of Cardiology, First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Clinical Medical Research Center for Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Erkun Xing
- Department of Cardiology, First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Clinical Medical Research Center for Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Jing Zhao
- Department of Cardiology, First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Clinical Medical Research Center for Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Fengmei Chen
- Department of Nuclear Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Ming Chen
- Department of Nuclear Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Andong Lu
- Department of Cardiology, First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Clinical Medical Research Center for Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Chenliang Pan
- Department of Cardiology, First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Clinical Medical Research Center for Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Lu Bai
- Department of Cardiology, First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Clinical Medical Research Center for Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Jing Zhang
- Department of Cardiology, First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Clinical Medical Research Center for Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Yongling Wa
- Department of Cardiology, First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Clinical Medical Research Center for Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Ting Wang
- Department of Cardiology, First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Clinical Medical Research Center for Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Yanhang Zhao
- Department of Cardiology, First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Clinical Medical Research Center for Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Xiaowei Niu
- Department of Cardiology, First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- Gansu Clinical Medical Research Center for Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Ming Bai
- Department of Cardiology, First Hospital of Lanzhou University, Lanzhou, Gansu, China.
- Gansu Key Laboratory of Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China.
- Gansu Clinical Medical Research Center for Cardiovascular Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China.
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China.
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Sharma SP, Sanz J, Hirsch A, Patel R, Constantinescu AA, Barghash M, Mancini DM, Brugts JJ, Caliskan K, Taverne YJHJ, Manintveld OC, Budde RPJ. Temporal changes in CT-derived fractional flow reserve in patients after heart transplantation. Eur Radiol 2025; 35:232-243. [PMID: 39014089 PMCID: PMC11631993 DOI: 10.1007/s00330-024-10932-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 05/09/2024] [Accepted: 06/06/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND Adding functional information by CT-derived fractional flow reserve (FFRct) to coronary CT angiography (CCTA) and assessing its temporal change may provide insight into the natural history and physiopathology of cardiac allograft vasculopathy (CAV) in heart transplantation (HTx) patients. We assessed FFRct changes as well as CAV progression over a 2-year period in HTx patients undergoing serial CT imaging. METHODS HTx patients from Erasmus MC and Mount Sinai Hospital, who had consecutive CCTAs 2 years apart were evaluated. FFRct analysis was performed for both scans. FFRct values at the most distal point in the left anterior descending (LAD), left circumflex (LCX), and right coronary artery (RCA) were measured after precisely matching the anatomical locations in both analyses. Also, the number of anatomical coronary stenoses of > 30% was scored. RESULTS In total, 106 patients (median age 57 [interquartile range 47-67] years, 67% male) at 9 [6-13] years after HTx at the time of the baseline CCTA were included. Median distal FFRct values significantly decreased from baseline to follow-up for the LAD from 0.85 [0.79-0.90] to 0.84 [0.76-0.90] (p = 0.001), LCX from 0.92 [0.88-0.96] to 0.91 [0.85-0.95] (p = 0.009), and RCA from 0.92 [0.86-0.95] to 0.90 [0.86-0.94] (p = 0.004). The number of focal anatomical stenoses of > 30% increased from a median of 1 [0-2] at baseline to 2 [0-3] at follow-up (p = 0.009). CONCLUSIONS The distal coronary FFRct values in post-HTX patients in each of the three major coronary arteries decreased, and the number of focal coronary stenoses increased over a 2-year period. Temporal FFRct change rate may become an additional parameter in the follow-up of HTx patients, but more research is needed to elucidate its role. CLINICAL RELEVANCE STATEMENT CT-derived fractional flow reserve (FFRct) is important post-heart transplant because of additional information on coronary CT angiography for cardiac allograft vasculopathy (CAV) detection. The decrease and degree of reduction in distal FFRct value may indicate progression in anatomic CAV burden. KEY POINTS CT-derived fractional flow reserve (FFRct) is important for monitoring cardiac allograft vasculopathy (CAV) in heart transplant patients. Over time, transplant patients showed a decrease in distal FFRct and an increase in coronary stenoses. Temporal changes in FFRct could be crucial for transplant follow-up, aiding in CAV detection.
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Affiliation(s)
- Simran P Sharma
- Department of Cardiology, Thorax Centre, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Javier Sanz
- Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
| | - Alexander Hirsch
- Department of Cardiology, Thorax Centre, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Richa Patel
- Department of Internal Medicine, Mount Sinai Hospital, New York, NY, USA
| | - Alina A Constantinescu
- Department of Cardiology, Thorax Centre, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Maya Barghash
- Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
| | - Donna M Mancini
- Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
| | - Jasper J Brugts
- Department of Cardiology, Thorax Centre, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Thorax Centre, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Yannick J H J Taverne
- Erasmus MC Transplant Institute, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Olivier C Manintveld
- Department of Cardiology, Thorax Centre, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Ricardo P J Budde
- Department of Cardiology, Thorax Centre, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
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Ma Y, Gao H, Wu H. Comparison of adverse cardiovascular event endpoints between patients with diabetes and patients without diabetes based on coronary artery plaques: a systematic review and meta-analysis. J Cardiothorac Surg 2024; 19:672. [PMID: 39707525 DOI: 10.1186/s13019-024-03157-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2024] [Accepted: 11/29/2024] [Indexed: 12/23/2024] Open
Abstract
BACKGROUND The classification of major adverse cardiovascular event (MACE) endpoints in patients with type 2 diabetes mellitus (T2DM) and either confirmed coronary artery disease (CAD) or high CAD risk, as well as the extent of the association between T2DM and coronary plaque characteristics, remains uncertain. PURPOSE This meta-analysis aims to compare MACE endpoints between patients with diabetes and patients without diabetes based on coronary artery plaques. METHODS We searched studies from Web of Science, PubMed, Embase, and the Cochrane Library up until September 1, 2023. Two independent researchers evaluated the quality and bias of the included studies. We used odds ratio (OR) and standardized mean difference (SMD) with 95% confidence interval (CI) to assess the effect of individual lesion parameters and coronary artery plaque characteristics on MACE endpoints. RESULTS Seven studies covered 1218 patients with diabetes and 3038 patients without diabetes. The follow-up time ranged from 2 to 5.4 years. The pooled results indicated that in all CAD lesions, DM was more strongly associated with MACE, myocardial infarction (MI), revascularization, and rehospitalization for unstable or progressive angina. The pooled OR was 1.82 (95% CI: 1.42 to 2.33, I2 = 0%, P < 0.00001) for MACE, 2.36 (95% CI: 1.47 to 3.79, I2 = 0%, P = 0.0004) for MI, 1.83 (95% CI: 1.33 to 2.53, I2 = 0%, P = 0.0002) for revascularization, and 1.65 (95% CI: 1.20 to 2.27, I2 = 0%, P = 0.002) for rehospitalization respectively. Subgroup analysis of culprit lesions (CLs) revealed significant differences between DM and non-DM for MACE, MI, revascularization, and stent thrombosis. While non-culprit lesions (NCLs) showed differences for MACE, MI, revascularization, and rehospitalization between the two groups. CONCLUSION The rates of MACE, MI, and revascularization are greater in DM than in non-DM patients in terms of all lesions, CLs, and NCLs. Except for CLs, the readmission rate is greater for unstable or progressive angina. Plaque characteristics are similar between patients with and without diabetes. Prospero registration number CRD42023474226.
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Affiliation(s)
- Yuchen Ma
- Department of Medical Informatics, Medical School of Nantong University, Nantong, 226001, China
| | - Huiying Gao
- Department of Medical Informatics, Medical School of Nantong University, Nantong, 226001, China
| | - Huiqun Wu
- Department of Medical Informatics, Medical School of Nantong University, Nantong, 226001, China.
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Bora N, Balogh O, Ferenci T, Piroth Z. Functional Assessment of Long-Term Microvascular Cardiac Allograft Vasculopathy. J Pers Med 2023; 13:1686. [PMID: 38138913 PMCID: PMC10744790 DOI: 10.3390/jpm13121686] [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: 09/25/2023] [Revised: 11/20/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is a leading cause of death and retransplantation following heart transplantation (HTX). Surveillance angiography performed yearly is indicated for the early detection of the disease, but it remains of limited sensitivity. METHODS We performed bolus thermodilution-based coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) and fractional flow reserve (FFR) measurements in HTX patients undergoing yearly surveillance coronary angiography without overt CAV. RESULTS In total, 27 HTX patients were included who had 52 CFR, IMR, and FFR measurements at a mean of 43 months after HTX. Only five measurements were performed in the first year. CFR decreased significantly by 0.13 every year (p = 0.04) and IMR tended to increase by 0.98 every year (p = 0.051), whereas FFR did not change (p = 0.161) and remained well above 0.80 over time. After one year, CFR decreased significantly (p = 0.022) and IMR increased significantly (p = 0.015), whereas FFR remained unchanged (p = 0.72). CONCLUSIONS The functional status of the epicardial coronary arteries of transplanted hearts did not deteriorate over time. On the contrary, a significant decrease in CFR was noted. In view of the increasing IMR, this is caused by the deterioration of the function of microvasculature. CFR and IMR measurements may provide an early opportunity to diagnose CAV.
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Affiliation(s)
- Noemi Bora
- Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary; (N.B.); (O.B.)
- Károly Rácz Doctoral School of Clinical Medicine, Semmelweis University, 1085 Budapest, Hungary
| | - Orsolya Balogh
- Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary; (N.B.); (O.B.)
| | - Tamás Ferenci
- Physiological Controls Group, John von Neumann Faculty of Informatics, Obuda University, 1034 Budapest, Hungary;
| | - Zsolt Piroth
- Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary; (N.B.); (O.B.)
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Rafique M, Solberg OG, Gullestad L, Bendz B, Murbræch K, Nytrøen K, Rolid K, Lunde K. Effects of high-intensity interval training on cardiac remodelling, function and coronary microcirculation in de novo heart transplant patients: a substudy of the HITTS randomised controlled trial. BMJ Open Sport Exerc Med 2023; 9:e001331. [PMID: 37440977 PMCID: PMC10335410 DOI: 10.1136/bmjsem-2022-001331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 07/15/2023] Open
Abstract
Objectives High-intensity interval training (HIT) improves peak oxygen consumption (VO2peak) in de novo heart transplant (HTx) recipients. It remains unclear whether this improvement early after HTx is solely dependent on peripheral adaptations, or due to a linked chain of central and peripheral adaptations. The objective of this study was to determine whether HIT results in structural and functional adaptations in the cardiovascular system. Methods Eighty-one de novo HTx recipients were randomly assigned to participate in either 9 months of supervised HIT or standard care exercise-based rehabilitation. Cardiac function was assessed by echocardiogram and the coronary microcirculation with the index of microcirculatory resistance (IMR) at baseline and 12 months after HTx. Results Cardiac function as assessed by global longitudinal strain was significantly better in the HIT group than in the standard care group (16.3±1.2% vs 15.6±2.2%, respectively, treatment effect = -1.1% (95% CI -2.0% to -0.2%), p=0.02), as was the end-diastolic volume (128.5±20.8 mL vs 123.4±15.5 mL, respectively, treatment effect=4.9 mL (95% CI 0.5 to 9.2 mL), p=0.03). There was a non-significant tendency for IMR to indicate improved microcirculatory function (13.8±8.0 vs 16.8±12.0, respectively, treatment effect = -4.3 (95% CI -9.1 to 0.6), p=0.08). Conclusion When initiated early after HTx, HIT leads to both structural and functional cardiovascular adaptations. Trial registration number NCT01796379.
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Affiliation(s)
- Muzammil Rafique
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ole Geir Solberg
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- KG Jebsen Center for Cardiac Research, University of Oslo, Oslo, Norway and Center for Heart Failure Research, Oslo University Hospital, Oslo, Norway
| | - Bjørn Bendz
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Klaus Murbræch
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kari Nytrøen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Katrine Rolid
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ketil Lunde
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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Iwańczyk S, Woźniak P, Smukowska-Gorynia A, Araszkiewicz A, Nowak A, Jankowski M, Konwerska A, Urbanowicz T, Lesiak M. Microcirculatory Disease in Patients after Heart Transplantation. J Clin Med 2023; 12:jcm12113838. [PMID: 37298033 DOI: 10.3390/jcm12113838] [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: 05/09/2023] [Revised: 05/25/2023] [Accepted: 06/02/2023] [Indexed: 06/12/2023] Open
Abstract
Although the treatment and prognosis of patients after heart transplantation have significantly improved, late graft dysfunction remains a critical problem. Two main subtypes of late graft dysfunction are currently described: acute allograft rejection and cardiac allograft vasculopathy, and microvascular dysfunction appears to be the first stage of both. Studies revealed that coronary microcirculation dysfunction, assessed by invasive methods in the early post-transplant period, correlates with a higher risk of late graft dysfunction and death during long-term follow-up. The index of microcirculatory resistance, measured early after heart transplantation, might identify the patients at higher risk of acute cellular rejection and major adverse cardiovascular events. It may also allow optimization and enhancement of post-transplantation management. Moreover, cardiac allograft vasculopathy is an independent prognostic factor for transplant rejection and survival rate. The studies showed that the index of microcirculatory resistance correlates with anatomic changes and reflects the deteriorating physiology of the epicardial arteries. In conclusion, invasive assessment of the coronary microcirculation, including the measurement of the microcirculatory resistance index, is a promising approach to predict graft dysfunction, especially the acute allograft rejection subtype, during the first year after heart transplantation. However, further advanced studies are needed to fully grasp the importance of microcirculatory dysfunction in patients after heart transplantation.
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Affiliation(s)
- Sylwia Iwańczyk
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Patrycja Woźniak
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Anna Smukowska-Gorynia
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | | | - Alicja Nowak
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Maurycy Jankowski
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, 60-701 Poznań, Poland
- Department of Histology and Embryology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Aneta Konwerska
- Department of Histology and Embryology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Tomasz Urbanowicz
- Cardiac Surgery and Transplantology Department, Poznan University of Medical Sciences, 60-701 Poznań, Poland
| | - Maciej Lesiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, 60-701 Poznań, Poland
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Shahandeh N, Song J, Saito K, Honda Y, Zimmermann FM, Ahn JM, Fearon WF, Parikh RV. Invasive Coronary Physiology in Heart Transplant Recipients: State-of-the-Art Review. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100627. [PMID: 39130712 PMCID: PMC11307478 DOI: 10.1016/j.jscai.2023.100627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/02/2023] [Accepted: 02/28/2023] [Indexed: 08/13/2024]
Abstract
Cardiac allograft vasculopathy is a leading cause of allograft failure and death among heart transplant recipients. Routine coronary angiography and intravascular ultrasound in the early posttransplant period are widely accepted as the current standard-of-care diagnostic modalities. However, many studies have now demonstrated that invasive coronary physiological assessment provides complementary long-term prognostic data and helps identify patients who are at risk of accelerated cardiac allograft vasculopathy and acute rejection.
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Affiliation(s)
- Negeen Shahandeh
- Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Justin Song
- Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Kan Saito
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Yasuhiro Honda
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | | | - Jung-Min Ahn
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - William F. Fearon
- Division of Cardiovascular Medicine, Stanford University and VA Palo Alto Health Care Systems, Stanford, California
| | - Rushi V. Parikh
- Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, California
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Fezzi S, Huang J, Lunardi M, Ding D, Ribichini FL, Tu S, Wijns W. Coronary physiology in the catheterisation laboratory: an A to Z practical guide. ASIAINTERVENTION 2022; 8:86-109. [PMID: 36798834 PMCID: PMC9890586 DOI: 10.4244/aij-d-22-00022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/21/2022] [Indexed: 11/16/2022]
Abstract
Coronary revascularisation, either percutaneous or surgical, aims to improve coronary flow and relieve myocardial ischaemia. The decision-making process in patients with coronary artery disease (CAD) remains largely based on invasive coronary angiography (ICA), even though until recently ICA could not assess the functional significance of coronary artery stenoses. Invasive wire-based approaches for physiological evaluations were developed to properly assess the ischaemic relevance of epicardial CAD. Fractional flow reserve (FFR) and later, instantaneous wave-free ratio (iFR), were shown to improve clinical outcomes in several patient subsets when used for coronary revascularisation guidance or deferral and for procedural optimisation of percutaneous coronary intervention (PCI) results. Despite accumulating evidence and positive guideline recommendations, the adoption of invasive physiology has remained quite low, mainly due to technical and economic issues as well as to operator-resistance to change. Coronary image-based computational physiology has been recently developed, with promising results in terms of accuracy and a reduction in computational time, costs, radiation exposure and risks for the patient. Lastly, the integration of intracoronary imaging and physiology allows for individualised PCI treatment, aiming at complete relief of ischaemia through optimised morpho-functional immediate procedural results. Instead of a conventional state-of-the-art review, this A to Z dictionary attempts to provide a practical guide for the application of coronary physiology in the catheterisation laboratory, exploring several methods, their pitfalls, and useful tips and tricks.
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Affiliation(s)
- Simone Fezzi
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Jiayue Huang
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Mattia Lunardi
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Daixin Ding
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Flavio L Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
- Department of Cardiology, Fujian Medical University Union Hospital, Fujian, China
| | - William Wijns
- The Lambe Institute for Translational Medicine, The Smart Sensors Lab and Curam, National University of Ireland, University Road, Galway, Ireland
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9
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Geng Y, Wu X, Liu H, Zheng D, Xia L. Index of microcirculatory resistance: state-of-the-art and potential applications in computational simulation of coronary artery disease. J Zhejiang Univ Sci B 2022; 23:123-140. [PMID: 35187886 DOI: 10.1631/jzus.b2100425] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The dysfunction of coronary microcirculation is an important cause of coronary artery disease (CAD). The index of microcirculatory resistance (IMR) is a quantitative evaluation of coronary microcirculatory function, which provides a significant reference for the prediction, diagnosis, treatment, and prognosis of CAD. IMR also plays a key role in investigating the interaction between epicardial and microcirculatory dysfunctions, and is closely associated with coronary hemodynamic parameters such as flow rate, distal coronary pressure, and aortic pressure, which have been widely applied in computational studies of CAD. However, there is currently a lack of consensus across studies on the normal and pathological ranges of IMR. The relationships between IMR and coronary hemodynamic parameters have not been accurately quantified, which limits the application of IMR in computational CAD studies. In this paper, we discuss the research gaps between IMR and its potential applications in the computational simulation of CAD. Computational simulation based on the combination of IMR and other hemodynamic parameters is a promising technology to improve the diagnosis and guide clinical trials of CAD.
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Affiliation(s)
- Yingyi Geng
- Key Laboratory for Biomedical Engineering of Ministry of Education, Institute of Biomedical Engineering, Zhejiang University, Hangzhou 310027, China
| | - Xintong Wu
- Key Laboratory for Biomedical Engineering of Ministry of Education, Institute of Biomedical Engineering, Zhejiang University, Hangzhou 310027, China
| | - Haipeng Liu
- Research Centre of Intelligent Healthcare, Faculty of Health and Life Science, Coventry University, Coventry CV1 5FB, UK
| | - Dingchang Zheng
- Research Centre of Intelligent Healthcare, Faculty of Health and Life Science, Coventry University, Coventry CV1 5FB, UK.
| | - Ling Xia
- Key Laboratory for Biomedical Engineering of Ministry of Education, Institute of Biomedical Engineering, Zhejiang University, Hangzhou 310027, China.
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10
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Mileva N, Nagumo S, Gallinoro E, Sonck J, Verstreken S, Dierkcx R, Heggermont W, Bartunek J, Goethals M, Heyse A, Barbato E, De Bruyne B, Collet C, Vanderheyden M. Validation of Coronary Angiography-Derived Vessel Fractional Flow Reserve in Heart Transplant Patients with Suspected Graft Vasculopathy. Diagnostics (Basel) 2021; 11:diagnostics11101750. [PMID: 34679451 PMCID: PMC8534544 DOI: 10.3390/diagnostics11101750] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 01/06/2023] Open
Abstract
Cardiac transplant-related vasculopathy remains a leading cause of morbidity and mortality in heart transplant (HTx) recipients. Recently, coronary angiography-derived vessel fractional flow reserve (vFFR) has emerged as a new diagnostic computational tool to functionally evaluate the severity of coronary artery disease. Although vFFR estimates have been shown to perform well against invasive FFR in atherosclerotic coronary artery disease, data on the use of vFFR in heart transplant recipients suffering from cardiac transplant-related arteriopathy are lacking. The aim of the presented study was to validate coronary angiography-derived vessel fractional flow reserve to calculate fractional flow reserve in HTx patients with and without cardiac transplant-related vasculopathy. A prospective, single center study of HTx patients referred for annual check-up, undergoing surveillance coronarography was conducted. Invasive FFR was measured using a motorized device at the speed of 1.0 mm/s in all three major coronary arteries. Angiography-derived pullback FFR was derived from the angiogram and compared with invasive FFR pullback curve. Overall, 18,059 FFR values were extracted from the FFR pullback curves from 23 HTx patients. The mean age was 59.3 ± 9.7 years, the mean time after transplantation was 5.24 years [IQR 1.20, 11.25]. A total of 39 vessels from 23 patients (24 LAD, 11 LCX, 4 RCA) were analyzed. Mean distal vFFR was 0.87 ± 0.14 whereas invasive distal FFR was 0.88 ± 0.17. An excellent correlation was found between invasive distal FFR and vFFR (r = 0.92; p < 0.001). The correlation of the pullback tracing was high, with a correlation coefficient between vFFR and invasive FFR pullback values of 0.72 (95% CI 0.71 to 0.73, p < 0.001). The mean difference between vFFR and invasive FFR pullback values was -0.01 with 0.06 of SD (limits of agreements -0.12 to 0.13). In HTx patients, coronary angiography-derived FFR correlates excellently with invasively measured wire-derived FFR. Therefore, angiography derived FFR could be used as a novel diagnostic tool to quantify the functional severity of graft vasculopathy.
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Affiliation(s)
- Niya Mileva
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
- Cardiology Clinic, Alexandrovska University Hospital, 1430 Sofia, Bulgaria
| | - Sakura Nagumo
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
- Department of Cardiology, Showa University Fujigaoka Hospital, Tokyo 8501, Japan
| | - Emanuele Gallinoro
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Naples, Italy
| | - Jeroen Sonck
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
- Department of Advanced Biomedical Sciences, University Federico II, 80131 Naples, Italy
| | - Sofie Verstreken
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
| | - Riet Dierkcx
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
| | - Ward Heggermont
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
| | - Jozef Bartunek
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
| | - Marc Goethals
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
| | - Alex Heyse
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
| | - Emanuele Barbato
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Naples, Italy
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
- Department of Cardiology, Lausanne University Hospital, 1100 Lausanne, Switzerland
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
| | - Marc Vanderheyden
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium; (N.M.); (S.N.); (E.G.); (J.S.); (S.V.); (R.D.); (W.H.); (J.B.); (M.G.); (A.H.); (E.B.); (B.D.B.); (C.C.)
- Correspondence: ; Tel.: +32-53-72-44-39
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11
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Sciaccaluga C, Ghionzoli N, Mandoli GE, Sisti N, D'Ascenzi F, Focardi M, Bernazzali S, Vergaro G, Emdin M, Valente S, Cameli M. The role of non-invasive imaging modalities in cardiac allograft vasculopathy: an updated focus on current evidences. Heart Fail Rev 2021; 27:1235-1246. [PMID: 34383194 PMCID: PMC9197817 DOI: 10.1007/s10741-021-10155-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 11/24/2022]
Abstract
Cardiac allograft vasculopathy (CAV) is an obliterative and diffuse form of vasculopathy affecting almost 50% of patients after 10 years from heart transplant and represents the most common cause of long-term cardiovascular mortality among heart transplant recipients. The gold standard diagnostic technique is still invasive coronary angiography, which however holds potential for complications, especially contrast-related kidney injury and procedure-related vascular lesions. Non-invasive and contrast-sparing imaging techniques have been advocated and investigated over the past decades, in order to identify those that could replace coronary angiography or at least reach comparable accuracy in CAV detection. In addition, they could help the clinician in defining optimal timing for invasive testing. This review attempts to examine the currently available non-invasive imaging techniques that may be used in the follow-up of heart transplant patients, spanning from echocardiography to nuclear imaging, cardiac magnetic resonance and cardiac computed tomography angiography, weighting their advantages and disadvantages.
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Affiliation(s)
- C Sciaccaluga
- Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy.
| | - N Ghionzoli
- 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
| | - F D'Ascenzi
- 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
| | - S Bernazzali
- Department of Cardiac Surgery, University Hospital of Siena, Siena, Italy
| | - G Vergaro
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - M Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - S Valente
- 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
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12
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Oxygen-sensitive Magnetic Resonance Imaging: A Noninvasive Step Forward for Diagnosing Vasculopathy in the Cardiac Allograft. Transplantation 2021; 105:1664-1665. [PMID: 32804799 DOI: 10.1097/tp.0000000000003420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Myocardial Vascular Function Assessed by Dynamic Oxygenation-sensitive Cardiac Magnetic Resonance Imaging Long-term Following Cardiac Transplantation. Transplantation 2021; 105:1347-1355. [PMID: 32804801 DOI: 10.1097/tp.0000000000003419] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Coronary vascular function is related to adverse outcomes following cardiac transplantation (CTx) in patients with or without cardiac allograft vasculopathy (CAV). The noninvasive assessment of the myocardial vascular response using oxygenation-sensitive cardiac magnetic resonance (OS-CMR has not been investigated in stable long-term CTx recipients). METHODS CTx patients were prospectively recruited to complete a CMR study with a breathing maneuver of hyperventilation followed by a voluntary apnea. Changes in OS-sensitive signal intensity reflecting the myocardial oxygenation response were monitored and expressed as % change in response to these breathing maneuvers. Myocardial injury was further investigated with T2-weighted imaging, native and postcontrast T1 measurements, extracellular volume measurements, and late gadolinium enhancement. RESULTS Forty-six CTx patients with (n = 23) and without (n = 23) CAV, along with 25 healthy controls (HC), were enrolled. The OS response was significantly attenuated in CTx compared with HC at the 30-second time-point into the breath-hold (2.63% ± 4.16% versus 6.40% ± 5.96%; P = 0.010). Compared with HC, OS response was lower in CTx without CAV (2.62% ± 4.60%; P < 0.05), while this response was further attenuated in patients with severe CAV (grades 2-3, -2.24% ± 3.65%). An inverse correlation was observed between OS-CMR, ventricular volumes, and diffuse fibrosis measured by extracellular volume mapping. CONCLUSIONS In heart transplant patients, myocardial oxygenation is impaired even in the absence of CAV suggesting microvascular dysfunction. These abnormalities can be identified by oxygenation-sensitive CMR using simple breathing maneuvers.
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14
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Mejia-Renteria H, Lee JM, Choi KH, Lee SH, Wang L, Kakuta T, Koo BK, Escaned J. Coronary microcirculation assessment using functional angiography: Development of a wire-free method applicable to conventional coronary angiograms. Catheter Cardiovasc Interv 2021; 98:1027-1037. [PMID: 34242489 DOI: 10.1002/ccd.29863] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/01/2021] [Accepted: 06/18/2021] [Indexed: 01/27/2023]
Abstract
OBJECTIVES We aimed to develop a novel wire- and adenosine-free microcirculatory resistive index from functional angiography (angio-IMR) to estimate coronary microcirculatory resistance, and to investigate how this method can improve clinical interpretation of physiological stenosis assessment with quantitative flow ratio (QFR). BACKGROUND Hyperemic index of coronary microcirculatory resistance (IMR) is a widely used tool to assess microcirculatory dysfunction. However, the need of dedicated intracoronary wire and hyperemia limits its adoption in clinical practice. METHODS We performed our study in two separate stages: (1) development of a formula (angio-IMR) to estimate IMR from resting angiograms and aortic pressure (Pa), and (2) validation of the method in a clinical population using invasively measured IMR as reference. Additionally, QFR diagnostic performance was assessed considering angio-IMR values. RESULTS We developed the formula: angio-IMR = (Pa-[0.1*Pa])*QFR*e-Tmn (where e-Tmn is an estimation of hyperaemic mean transit time) and validated it in 115 vessels (104 patients). Angio-IMR correlated well with IMR (Spearman's rho = 0.70, p < 0.001). Sensitivity, specificity, positive and negative predictive value, accuracy and area under the curve of angio-IMR to predict IMR were 87.5% (73.2-95.8), 85.3% (75.3-92.4), 76.1% (64.5-84.8), 92.8% (84.9-96.7), 85% and 0.90 (0.83-0.95), respectively. False positive QFR measurements decreased from 19.5% to 8.5% when angio-IMR was incorporated into the QFR interpretation workflow. CONCLUSIONS Estimation of IMR without physiology wire and adenosine is feasible. Coronary microcirculatory dysfunction causing high IMR can be ruled-out with high confidence in vessels with low angio-IMR. Awareness of angio-IMR contributes to a better clinical interpretation of functional stenosis assessment with QFR.
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Affiliation(s)
- Hernan Mejia-Renteria
- Department of Cardiology, Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ki-Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung-Hun Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Lin Wang
- Department of Cardiology, Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
- The Institute on Aging, Seoul National University, Seoul, South Korea
| | - Javier Escaned
- Department of Cardiology, Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
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15
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Abstract
Heart transplantation (HTx) remains the optimal treatment for selected patients with end-stage advanced heart failure. However, survival is limited early by acute rejection and long term by cardiac allograft vasculopathy (CAV). Even though the diagnosis of rejection is based on histology, cardiac imaging provides a pivotal role for early detection and severity assessment of these hazards. The present review focuses on the use and reliability of different invasive and non-invasive imaging modalities to detect and monitor CAV and rejection after HTx. Coronary angiography remains the corner stone in routine CAV surveillance. However, angiograms are invasive and underestimates the CAV severity especially in the early phase. Intravascular ultrasound and optical coherence tomography are invasive methods for intracoronary imaging that detects early CAV lesions not evident by angiograms. Non-invasive imaging can be divided into myocardial perfusion imaging, anatomical/structural imaging and myocardial functional imaging. The different non-invasive imaging modalities all provide clinical and prognostic information and may have a gatekeeper role for invasive monitoring. Acute rejection and CAV are still significant clinical problems after HTx. No imaging modality provides complete information on graft function, coronary anatomy and myocardial perfusion. However, a combination of invasive and non-invasive modalities at different stages following HTx should be considered for optimal personalized surveillance and risk stratification.
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Affiliation(s)
| | | | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Denmark
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16
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“Cardiac allograft vasculopathy: Pathogenesis, diagnosis and therapy”. Transplant Rev (Orlando) 2020; 34:100569. [DOI: 10.1016/j.trre.2020.100569] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/19/2020] [Indexed: 01/06/2023]
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17
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Vessel Fractional Flow Reserve and Graft Vasculopathy in Heart Transplant Recipients. J Interv Cardiol 2020; 2020:9835151. [PMID: 32733172 PMCID: PMC7376430 DOI: 10.1155/2020/9835151] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 05/12/2020] [Indexed: 11/18/2022] Open
Abstract
Background Cardiac allograft vasculopathy (CAV) remains the Achilles' heel of long-term survival after heart transplantation (HTx). The severity and extent of CAV is graded with conventional coronary angiography (COR) which has several limitations. Recently, vessel fractional flow reserve (vFFR) derived from COR has emerged as a diagnostic computational tool to quantify the functional severity of coronary artery disease. Purpose The present study assessed the usefulness of vFFR to detect CAV in HTx recipients. Methods In HTx patients referred for annual check-up, undergoing surveillance COR, the extent of CAV was graded according to the criteria proposed by the international society of heart and lung transplantation (ISHLT). In addition, three-dimensional coronary geometries were constructed from COR to calculate pressure losses using vFFR. Results In 65 HTx patients with a mean age of 53.7 ± 10.1 years, 8.5 years (IQR 1.90, 15.2) years after HTx, a total number of 173 vessels (59 LAD, 61 LCX, and 53 RCA) were analyzed. The mean vFFR was 0.84 ± 0.15 and median was 0.88 (IQR 0.79, 0.94). A vFFR ≤ 0.80 was present in 24 patients (48 vessels). HTx patients with a history of ischemic cardiomyopathy (ICMP) had numerically lower vFFR as compared to those with non-ICMP (0.70 ± 0.22 vs. 0.79 ± 0.13, p = 0.06). The use of vFFR reclassified 31.9% of patients compared to the anatomical ISHLT criteria. Despite a CAV score of 0, a pathological vFFR ≤ 0.80 was detected in 8 patients (34.8%). Conclusion The impairment in epicardial conductance assessed by vFFR in a subgroup of patients without CAV according to standard ISHLT criteria suggests the presence of a diffuse vasculopathy undetectable by conventional angiography. Therefore, we speculate that vFFR may be useful in risk stratification after HTx.
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18
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The role of optical coherence tomography and other intravascular imaging modalities in cardiac allograft vasculopathy. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2020; 16:19-29. [PMID: 32368233 PMCID: PMC7189132 DOI: 10.5114/aic.2020.93909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/13/2020] [Indexed: 11/17/2022] Open
Abstract
Orthotopic heart transplantation (OHT) is the standard-of-care for end-stage heart disease. Although a significant improvement in the prognosis of patients after OHT has been observed in recent years, their overall mortality remains relatively high, with a median survival of approximately 10 years after transplantation. One of the primary causes of death in patients after OHT is cardiac allograft vasculopathy (CAV), the condition developing specifically in the coronary vasculature after OHT, the pathophysiology of which is still inadequately known. It is estimated that CAV development and progression is responsible for approximately 30% of deaths within five years post-OHT. According to the International Society for Heart and Lung Transplantation (ISHLT) Nomenclature for CAV, its presence should be assessed primarily by the coronary angiography performed routinely after OHT, mostly due to its wide availability, reproducibility, and low complication rate. However, the analysis of CAV in coronary angiography has limitations, mostly concerning its - sometimes inadequate - sensitivity and specificity. Hence, there is a growing need for the introduction of more accurate methods of CAV assessment, such as intravascular imaging, which through a thorough evaluation of the arterial wall structure and thickness allows the drawbacks of routine angiography to be minimised. The aim of the article was to critically summarise the current findings derived from the analysis of CAV by optical coherence tomography, the other intravascular imaging modalities, such as intravascular ultrasound (IVUS) and IVUS-derived virtual histology, along with physiological assessment with the use of the fractional flow reserve.
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19
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Miller RJH, Kwiecinski J, Shah KS, Eisenberg E, Patel J, Kobashigawa JA, Azarbal B, Tamarappoo B, Berman DS, Slomka PJ, Kransdorf E, Dey D. Coronary computed tomography-angiography quantitative plaque analysis improves detection of early cardiac allograft vasculopathy: A pilot study. Am J Transplant 2020; 20:1375-1383. [PMID: 31758640 DOI: 10.1111/ajt.15721] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/30/2019] [Accepted: 11/15/2019] [Indexed: 01/25/2023]
Abstract
Cardiac allograft vasculopathy (CAV) is an increasingly important complication after cardiac transplant. We assessed the additive diagnostic benefit of quantitative plaque analysis in patients undergoing coronary computed tomography-angiography (CCTA). Consecutive patients undergoing CCTA for CAV surveillance were identified. Scans were visually interpreted for coronary stenosis. Semiautomated software was used to quantify noncalcified plaque (NCP), as well as its components. Optimal diagnostic cut-offs for CAV, with coronary angiography as gold standard, were defined using receiver operating characteristic curves. In total, 36 scans were identified in 17 patients. CAV was present in 17 (46.0%) reference coronary angiograms, at a median of 1.9 years before CCTA. Median NCP (147 vs 58, P < .001), low-density NCP (median 4.5 vs 0.9, P = .003), fibrous plaque (median 76.1 vs 31.1, P = .003), and fibrofatty plaque (median 63.6 vs 27.6, P < .001) volumes were higher in patients with CAV, whereas calcified plaque was not (median 0.0 vs 0.0, P = .510). Visual assessment of CCTA alone was 70.6% sensitive and 100% specific for CAV. The addition of total NCP volume increased sensitivity to 82.4% while maintaining 100% specificity. NCP volume is significantly higher in patients with CAV. The addition of quantitative analysis to visual interpretation improves the sensitivity for detecting CAV without reducing specificity.
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Affiliation(s)
- Robert J H Miller
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA.,Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jacek Kwiecinski
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA.,Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Kevin S Shah
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Evann Eisenberg
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Babak Azarbal
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Balaji Tamarappoo
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Daniel S Berman
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Piotr J Slomka
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Evan Kransdorf
- Smidt Heart Institute, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Damini Dey
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
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20
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DeSa TB, Abbasi MA, Blaisdell JA, Lin K, Collins JD, Carr JC, Markl M. Semi-quantitative myocardial perfusion MRI in heart transplant recipients at rest: repeatability in healthy controls and assessment of cardiac allograft vasculopathy. Clin Imaging 2019; 61:62-68. [PMID: 31981959 DOI: 10.1016/j.clinimag.2019.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 11/25/2019] [Accepted: 12/16/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cardiac Allograft Vasculopathy (CAV) is a major cause of chronic cardiac allograft failure. Invasive coronary angiography (ICA) and intravascular ultrasound (IVUS) are the current diagnostic methods. Myocardial perfusion MRI has become a promising non-invasive method to evaluate myocardial ischemia, but has not been thoroughly validated in CAV. Our objective was to assess the repeatability of myocardial rest-perfusion MRI in healthy volunteers and its feasibility in detecting CAV in transplant patients (Tx). METHODS Twelve healthy volunteers and twenty transplant patients beyond the first year post- transplant underwent cardiac MRI at 1.5 T at rest including first-pass perfusion imaging in short axis (base, mid, apex) after injection of gadolinium. Volunteers underwent repeated cardiac MRI on different days (interval = 15.6 ± 2.4 days) to assess repeatability. Data analysis included semi-automatic contouring of endocardial and epicardial borders of the left ventricle (LV) and quantification of peak perfusion, time-to-peak (TTP) perfusion, and upslope of the perfusion curve. RESULTS Between scans and re-scans in healthy volunteers, peak signal intensity, slope, and TTP demonstrated moderate agreement (ICC = 0.53, 0.48, and 0.59, respectively; all, p < .001). Peak signal intensity, slope, and TTP were moderately variable with COV values of 23%, 42%, and 35%, respectively. Peak perfusion was significantly reduced in CAV positive (n = 9 Tx patients) compared to CAV negative (n = 11 Tx patients) groups (90.7 ± 27.0 vs 139.5 ± 30.2, p < .001). CONCLUSION Cardiac MRI is a moderately repeatable method for the semi-quantitative assessment of first-pass myocardial perfusion at rest. Semi-quantitative surrogate markers of LV perfusion could play a role in CAV detection.
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Affiliation(s)
- Travis B DeSa
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA.
| | - Muhannad A Abbasi
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA
| | - Julie A Blaisdell
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA
| | - Kai Lin
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA
| | - Jeremy D Collins
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA; Mayo Clinic, Department of Radiology, Rochester, MN, USA
| | - James C Carr
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA
| | - Michael Markl
- Northwestern University Feinberg School of Medicine, Department of Diagnostic Radiology, 737 N. Michigan Avenue Suite 1600, Chicago, IL 60611, USA; Northwestern University McCormick School of Engineering, Department of Biomedical Engineering, 2145 Sheridan Rd, Evanston, IL 60208, USA
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21
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Lee MS, Tadwalkar RV, Fearon WF, Kirtane AJ, Patel AJ, Patel CB, Ali Z, Rao SV. Cardiac allograft vasculopathy: A review. Catheter Cardiovasc Interv 2018; 92:E527-E536. [DOI: 10.1002/ccd.27893] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 08/29/2018] [Indexed: 01/19/2023]
Affiliation(s)
- Michael S. Lee
- Division of Cardiology, UCLA Medical Center Los Angeles California
| | | | - William F. Fearon
- Division of CardiologyStanford University School of Medicine Stanford California
| | - Ajay J. Kirtane
- Division of CardiologyColumbia University Medical Center New York New York
| | - Amisha J. Patel
- Division of CardiologyColumbia University Medical Center New York New York
| | - Chetan B. Patel
- Division of CardiologyDuke University Medical Center Durham North Carolina
| | - Ziad Ali
- Division of CardiologyColumbia University Medical Center New York New York
| | - Sunil V. Rao
- Division of CardiologyDuke University Medical Center Durham North Carolina
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22
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Chih S, Chong AY, Erthal F, deKemp RA, Davies RA, Stadnick E, So DY, Overgaard C, Wells G, Mielniczuk LM, Beanlands RS. PET Assessment of Epicardial Intimal Disease and Microvascular Dysfunction in Cardiac Allograft Vasculopathy. J Am Coll Cardiol 2018; 71:1444-1456. [DOI: 10.1016/j.jacc.2018.01.062] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 12/30/2017] [Accepted: 01/19/2018] [Indexed: 11/17/2022]
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23
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Abstract
Traditionally, invasive coronary physiological assessment has focused on the epicardial coronary artery. More recently, appreciation of the importance of the coronary microvasculature in determining patient outcomes has grown. Several invasive modalities for interrogating microvascular function have been proposed. Angiographic techniques have been limited by their qualitative and subjective nature. Doppler wire-derived coronary flow reserve has been applied in research studies, but its clinical role has been limited by its lack of reproducibility, its lack of a clear normal value, and the fact that it is not specific for the microvasculature but interrogates the entire coronary circulation. The index of microcirculatory resistance—a thermodilution-derived measure of the minimum achievable microvascular resistance—is relatively easy to measure, more reproducible, has a clearer normal value, and is independent of epicardial coronary artery stenosis. The index of microcirculatory resistance has been shown to have prognostic value in patients with ST-segment–elevation myocardial infarction and cardiac allograft vasculopathy after heart transplantation. Emerging data demonstrate its role in evaluating patients with chest pain and nonobstructive coronary artery disease. Increasingly, the index of microcirculatory resistance is used as a reference standard for invasively assessing the microvasculature in clinical trials.
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Affiliation(s)
- William F. Fearon
- From the Division of Cardiovascular Medicine, Stanford University, CA
| | - Yuhei Kobayashi
- From the Division of Cardiovascular Medicine, Stanford University, CA
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24
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Parikh RV, Khush KK, Luikart H, Pargaonkar VS, Kobayashi Y, Lee JH, Sinha S, Cohen G, Valantine HA, Yeung AC, Fearon WF. Impact of Asymmetric Dimethylarginine on Coronary Physiology Early After Heart Transplantation. Am J Cardiol 2017; 120:1020-1025. [PMID: 28754566 DOI: 10.1016/j.amjcard.2017.06.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 05/25/2017] [Accepted: 06/13/2017] [Indexed: 11/26/2022]
Abstract
Cardiac allograft vasculopathy is a major cause of long-term graft failure following heart transplantation. Asymmetric dimethylarginine (ADMA), a marker of endothelial dysfunction, has been mechanistically implicated in the development of cardiac allograft vasculopathy, but its impact on coronary physiology early after transplantation is unknown. Invasive indices of coronary physiology, namely, fractional flow reserve (FFR), the index of microcirculatory resistance, and coronary flow reserve, were measured with a coronary pressure wire in the left anterior descending artery within 8 weeks (baseline) and 1 year after transplant. Plasma levels of ADMA were concurrently assayed using high-performance liquid chromatography. In 46 heart transplant recipients, there was a statistically significant correlation between elevated ADMA levels and lower FFR values at baseline (r = -0.33; p = 0.024); this modest association persisted 1 year after transplant (r = -0.39; p = 0.0085). Patients with a baseline FFR <0.90 (a prognostically validated cutoff) had significantly higher baseline ADMA levels (0.63 ± 0.16 vs 0.54 ± 0.12 µM; p = 0.034). Baseline ADMA (odds ratio 1.80 per 0.1 µM; 95% confidence interval 1.07 to 3.03; p = 0.027) independently predicted a baseline FFR <0.90 after multivariable adjustment. Even after dichotomizing ADMA (≥0.60 µM, provides greatest diagnostic accuracy by receiver operating characteristic curve), this association remained significant (odds ratio 7.52, 95% confidence interval 1.74 to 32.49; p = 0.006). No significant relationship between ADMA and index of microcirculatory resistance or coronary flow reserve was detected. In conclusion, baseline ADMA was a strong independent predictor of FFR <0.90, suggesting that elevated ADMA levels are associated with abnormal epicardial function soon after heart transplantation.
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25
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Fearon WF, Felix R, Hirohata A, Sakurai R, Jose PO, Yamasaki M, Nakamura M, Fitzgerald PJ, Valantine HA, Yock PG, Yeung AC. The effect of negative remodeling on fractional flow reserve after cardiac transplantation. Int J Cardiol 2017; 241:283-287. [PMID: 28413112 DOI: 10.1016/j.ijcard.2017.04.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 04/01/2017] [Accepted: 04/07/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Negative remodeling is a common occurrence early after cardiac transplantation. Its impact on the development of myocardial ischemia is not well documented. The aim of this study is to investigate the impact of negative remodeling on fractional flow reserve after cardiac transplantation. METHODS Thirty-four cardiac transplant recipients underwent intravascular ultrasound (IVUS) and fractional flow reserve (FFR) assessment soon after transplantation and one year later. Patients were divided into those with and without negative remodeling based on IVUS, and the impact on FFR was assessed. In the 19 patients with negative remodeling, there was no significant change in plaque volume (119.3±82.0 to 131.3±91.2mm3, p=0.21), but vessel volume (775.6±212.0 to 621.9±144.1mm3, p<0.0001) and lumen volume (656.3±169.1 to 490.7±132.0mm3, p<0.0001) decreased significantly and FFR likewise decreased significantly (0.88±0.06 to 0.84±0.07, p=0.04). In the 15 patients without negative remodeling, vessel volume did not change (711.7±217.6 to 745.7±198.5, p=0.28), but there was a significant increase in plaque volume (126.8±88.3 to 194.4±92.7, p<0.001) and a resultant significant decrease in FFR (0.89±0.05 to 0.85±0.05, p=0.01). CONCLUSION Negative remodeling itself, without any change in plaque volume can cause a significant decrease in fractional flow reserve after cardiac transplantation and appears to be another possible mechanism for myocardial ischemia.
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Affiliation(s)
- William F Fearon
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States.
| | - Robert Felix
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| | - Atsushi Hirohata
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| | - Ryota Sakurai
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| | - Powell O Jose
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| | - Masao Yamasaki
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| | - Mamoo Nakamura
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| | - Peter J Fitzgerald
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| | - Hannah A Valantine
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| | - Paul G Yock
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
| | - Alan C Yeung
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA, United States
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26
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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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27
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Ahmed B, Mondragon J, Sheldon M, Clegg S. Impact of ranolazine on coronary microvascular dysfunction (MICRO) study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 18:431-435. [PMID: 28576663 DOI: 10.1016/j.carrev.2017.04.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/13/2017] [Accepted: 04/19/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients with angina and coronary microvascular dysfunction, without evidence of structural or epicardial coronary disease (Type I CMVD) remain without evidence based treatment options. Previous work has demonstrated that ranolazine can improve angina frequency and stability among patients with Type 1 CMVD; however, the mechanism remains unclear. Therefore, the objective of this pilot project was to assess the impact of ranolazine on Type I CMVD as measured using an invasive tool to measure global resistance (index of microcirculatory resistance (IMR)). METHODS Patients with Type 1 CMVD diagnosed using IMR were enrolled and treated with ranolazine 1000mg BID. Coronary angiography and IMR were performed at baseline and on treatment after four weeks. The primary outcome measure was change in IMR pre- and post-treatment. Secondary outcome measures, improvement in angina and activity level, were assessed using the Seattle Angina Questionnaire (SAQ), Duke Activity Status Index (DASI) and Metabolic equivalent for Task (MET) scores. RESULTS A total of 7 patient were enrolled and completed the study. Mean age was 57.6±7.5, 43% were female and 43% were Hispanic. Mean baseline IMR was 37.25±16.27 which decreased to 19.48±5.69 (p=0.02; (-48% Δ) after treatment with ranolazine. Four of the five SAQ domains improved on treatment with significant improvement in physical limitation (p=0.001), angina frequency (p=0.04), angina stability (p=0.05) and disease perception (p=0.001). Non-significant improvements in activity were also seen in both the DASI and MET scores. CONCLUSION Among patients with Type 1 CMVD, our pilot data suggest favorable changes in IMR, anginal symptoms and activity status with ranolazine treatment. These findings support further evaluation of the effects of ranolazine on microcirculatory function and angina symptoms in a larger cohort of patients with Type 1 CMVD.
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Affiliation(s)
- Bina Ahmed
- Dartmouth Hitchcock Medical Center, Lebanon, NH, United States.
| | - Judith Mondragon
- University of New Mexico Health Science Center, Albuquerque, NM, United States
| | - Mark Sheldon
- University of New Mexico Health Science Center, Albuquerque, NM, United States
| | - Stacey Clegg
- University of New Mexico Health Science Center, Albuquerque, NM, United States
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28
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Chih S, Ross HJ, Alba AC, Fan CS, Manlhiot C, Crean AM. Perfusion Cardiac Magnetic Resonance Imaging as a Rule-Out Test for Cardiac Allograft Vasculopathy. Am J Transplant 2016; 16:3007-3015. [PMID: 27140676 DOI: 10.1111/ajt.13839] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 03/22/2016] [Accepted: 04/16/2016] [Indexed: 01/25/2023]
Abstract
Cardiac allograft vasculopathy (CAV) is a leading cause of mortality after heart transplantation. Noninvasive imaging techniques used in CAV evaluation have important limitations. In a cross-sectional study, we investigated perfusion cardiac magnetic resonance (CMR) imaging to determine an optimal myocardial perfusion reserve index (MPR) cutoff for detecting CAV using receiver operating characteristic curve analysis. We evaluated CMR performance using sensitivity, specificity and likelihood ratio analysis. We included 29 patients (mean 5 ± 4 years after transplant) scheduled for coronary angiography with intravascular ultrasound (IVUS) who completed CMR. CAV was defined as maximal intimal thickness (MIT) >0.5 mm by IVUS of the left anterior descending artery. CAV was evident in 19 patients (70%) on IVUS (mean MIT 0.82 ± 0.42 mm). MPR was significantly lower in patients with MIT ≥0.50 mm (1.35 ± 0.23 vs. 1.71 ± 0.45, p = 0.013). There was moderate inverse correlation between MPR and MIT (r = -0.36, p = 0.075). The optimal MPR cutoff ≤1.68 for predicting CAV showed sensitivity of 100%, specificity of 63%, a negative predictive value of 100%, a positive predictive value of 86% and a positive likelihood ratio of 2.7. An MPR ≤1.68 has high negative predictive value, suggesting its potential as a test to rule out CAV.
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Affiliation(s)
- S Chih
- Heart Failure-Transplantation, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada
| | - H J Ross
- Division of Cardiology, Toronto General Hospital-University Health Network, Toronto, Canada
| | - A C Alba
- Division of Cardiology, Toronto General Hospital-University Health Network, Toronto, Canada
| | - C S Fan
- Cardiovascular Data Management Centre, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - C Manlhiot
- Cardiovascular Data Management Centre, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - A M Crean
- Division of Cardiology, Toronto General Hospital-University Health Network, Toronto, Canada
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29
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Pedrotti P, Vittori C, Facchetti R, Pedretti S, Dellegrottaglie S, Milazzo A, Frigerio M, Cipriani M, Giannattasio C, Roghi A, Rimoldi O. Prognostic impact of late gadolinium enhancement in the risk stratification of heart transplant patients. Eur Heart J Cardiovasc Imaging 2016; 18:130-137. [DOI: 10.1093/ehjci/jew186] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 08/11/2016] [Indexed: 11/15/2022] Open
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30
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Index of microvascular resistance after early conversion from calcineurin inhibitor to everolimus in heart transplantation: A sub-study to a 1-year randomized trial. J Heart Lung Transplant 2016; 35:1010-7. [DOI: 10.1016/j.healun.2016.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 02/13/2016] [Accepted: 03/11/2016] [Indexed: 11/21/2022] Open
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31
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Leite L, Matos V, Gonçalves L, Silva Marques J, Jorge E, Calisto J, Antunes M, Pego M. Heart transplant coronary artery disease: Multimodality approach in percutaneous intervention. Rev Port Cardiol 2016; 35:377.e1-5. [DOI: 10.1016/j.repc.2015.09.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 09/13/2015] [Indexed: 10/21/2022] Open
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32
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Leite L, Matos V, Gonçalves L, Silva Marques J, Jorge E, Calisto J, Antunes M, Pego M. Heart transplant coronary artery disease: Multimodality approach in percutaneous intervention. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.repce.2015.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Picard F, Tadros VX, Pighi M, Spagnoli V, De Hemptinne Q, Ly HQ. [Fractional flow reserve and instantaneous wave-free ratio for the physiological assessment of coronary artery stenosis in the catheterization laboratory: Practical tips]. Ann Cardiol Angeiol (Paris) 2016; 66:32-41. [PMID: 27211352 DOI: 10.1016/j.ancard.2016.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 03/15/2016] [Indexed: 01/14/2023]
Abstract
In recent years, a large body of evidence has revealed the limitations of angiographic evaluation in determining the physiological significance of coronary stenosis, particularly when these are intermediate lesions. Percutaneous coronary interventions (PCI) guided by physiological assessment using fractional flow reserve (FFR) have been shown to reduce cardiovascular events when compared to angiography alone. Recently, another coronary physiologic parameter has been introduced: the "instantaneous wave-free ratio" (iFR). In this review, we will discuss the FFR, the iFR, and their use in the functional assessment of coronary stenosis in the cardiac catheterization laboratory. This review will cover theoretical aspects for non-interventional cardiologists, as well as practice points and common pitfalls related to coronary physiological assessment for interventional cardiologists.
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Affiliation(s)
- F Picard
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, université de Montréal, Montréal, QC, Canada
| | - V X Tadros
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, université de Montréal, Montréal, QC, Canada
| | - M Pighi
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, université de Montréal, Montréal, QC, Canada
| | - V Spagnoli
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, université de Montréal, Montréal, QC, Canada
| | - Q De Hemptinne
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, université de Montréal, Montréal, QC, Canada
| | - H Q Ly
- Interventional Cardiology Division, Department of Medicine, Montreal Heart Institute, université de Montréal, Montréal, QC, Canada.
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34
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The index of microcirculatory resistance in the physiologic assessment of the coronary microcirculation. Coron Artery Dis 2016; 26 Suppl 1:e15-26. [PMID: 26247265 DOI: 10.1097/mca.0000000000000213] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The coronary microcirculation plays a critical role in normal cardiac physiology as well as in many disease states. However, methods to evaluate the function of the coronary microvessels have been limited by technical and theoretical issues. Recently, the index of microcirculatory resistance (IMR) has been proposed and validated as a simple and specific invasive method of assessing the coronary microcirculation. By relying on the thermodilution theory and using a pressure-temperature sensor guidewire, IMR provides a measurement of the minimum achievable microcirculatory resistance in a target coronary artery territory, enabling a quantitative assessment of the microvascular integrity. Unlike indices such as coronary flow reserve, IMR is highly reproducible and independent of hemodynamic changes. In ST-elevation myocardial infarction, IMR predicts myocardial recovery and long-term mortality, whereas in patients with stable coronary artery disease, preintervention IMR predicts the occurrence of periprocedural myocardial infarction. Increasingly, research has focused on IMR-guided interventions of the microcirculation, with the aim of preventing and/or treating the microcirculatory dysfunction that commonly accompanies the epicardial coronary disease. In the present review, we will discuss the theoretical and practical basis for IMR, the clinical studies supporting it, and the future lines of research using this novel tool.
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35
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Yang HM, Khush K, Luikart H, Okada K, Lim HS, Kobayashi Y, Honda Y, Yeung AC, Valantine H, Fearon WF. Invasive Assessment of Coronary Physiology Predicts Late Mortality After Heart Transplantation. Circulation 2016; 133:1945-50. [PMID: 27143679 DOI: 10.1161/circulationaha.115.018741] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 03/14/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The aim of this study is to determine the prognostic value of invasively assessing coronary physiology early after heart transplantation. METHODS AND RESULTS Seventy-four cardiac transplant recipients had fractional flow reserve, coronary flow reserve, index of microcirculatory resistance (IMR), and intravascular ultrasound performed down the left anterior descending coronary artery soon after (baseline) and 1 year after heart transplantation. The primary end point was the cumulative survival free of death or retransplantation at a mean follow-up of 4.5±3.5 years. The cumulative event-free survival was significantly lower in patients with a fractional flow reserve <0.90 at baseline (42% versus 79%; P=0.01) or an IMR ≥20 measured 1 year after heart transplantation (39% versus 69%; P=0.03). Patients in whom IMR decreased or did not change from baseline to 1 year had higher event-free survival compared with patients with an increase in IMR (66% versus 36%; P=0.03). Fractional flow reserve <0.90 at baseline (hazard ratio, 0.13; 95% confidence interval, 0.02-0.81; P=0.03), IMR ≥20 at 1 year (hazard ratio, 3.93; 95% confidence interval, 1.08-14.27; P=0.04), and rejection during the first year (hazard ratio, 6.00; 95% confidence interval, 1.56-23.09; P=0.009) were independent predictors of death/retransplantation, whereas intravascular ultrasound parameters were not. CONCLUSIONS Invasive measures of coronary physiology (fractional flow reserve and IMR) determined early after heart transplantation are significant predictors of late death or retransplantation.
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Affiliation(s)
- Hyoung-Mo Yang
- From Stanford University, Stanford, CA (H.-M.Y., K.K., H.L., K.O., H.-S.L., Y.K., Y.H., A.C.Y., H.V., W.F.F.); and Ajou University School of Medicine, Suwon, South Korea (H.-M.Y., H.-S.L.)
| | - Kiran Khush
- From Stanford University, Stanford, CA (H.-M.Y., K.K., H.L., K.O., H.-S.L., Y.K., Y.H., A.C.Y., H.V., W.F.F.); and Ajou University School of Medicine, Suwon, South Korea (H.-M.Y., H.-S.L.)
| | - Helen Luikart
- From Stanford University, Stanford, CA (H.-M.Y., K.K., H.L., K.O., H.-S.L., Y.K., Y.H., A.C.Y., H.V., W.F.F.); and Ajou University School of Medicine, Suwon, South Korea (H.-M.Y., H.-S.L.)
| | - Kozo Okada
- From Stanford University, Stanford, CA (H.-M.Y., K.K., H.L., K.O., H.-S.L., Y.K., Y.H., A.C.Y., H.V., W.F.F.); and Ajou University School of Medicine, Suwon, South Korea (H.-M.Y., H.-S.L.)
| | - Hong-Seok Lim
- From Stanford University, Stanford, CA (H.-M.Y., K.K., H.L., K.O., H.-S.L., Y.K., Y.H., A.C.Y., H.V., W.F.F.); and Ajou University School of Medicine, Suwon, South Korea (H.-M.Y., H.-S.L.)
| | - Yuhei Kobayashi
- From Stanford University, Stanford, CA (H.-M.Y., K.K., H.L., K.O., H.-S.L., Y.K., Y.H., A.C.Y., H.V., W.F.F.); and Ajou University School of Medicine, Suwon, South Korea (H.-M.Y., H.-S.L.)
| | - Yasuhiro Honda
- From Stanford University, Stanford, CA (H.-M.Y., K.K., H.L., K.O., H.-S.L., Y.K., Y.H., A.C.Y., H.V., W.F.F.); and Ajou University School of Medicine, Suwon, South Korea (H.-M.Y., H.-S.L.)
| | - Alan C Yeung
- From Stanford University, Stanford, CA (H.-M.Y., K.K., H.L., K.O., H.-S.L., Y.K., Y.H., A.C.Y., H.V., W.F.F.); and Ajou University School of Medicine, Suwon, South Korea (H.-M.Y., H.-S.L.)
| | - Hannah Valantine
- From Stanford University, Stanford, CA (H.-M.Y., K.K., H.L., K.O., H.-S.L., Y.K., Y.H., A.C.Y., H.V., W.F.F.); and Ajou University School of Medicine, Suwon, South Korea (H.-M.Y., H.-S.L.)
| | - William F Fearon
- From Stanford University, Stanford, CA (H.-M.Y., K.K., H.L., K.O., H.-S.L., Y.K., Y.H., A.C.Y., H.V., W.F.F.); and Ajou University School of Medicine, Suwon, South Korea (H.-M.Y., H.-S.L.).
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Erbel C, Mukhammadaminova N, Gleissner CA, Osman NF, Hofmann NP, Steuer C, Akhavanpoor M, Wangler S, Celik S, Doesch AO, Voss A, Buss SJ, Schnabel PA, Katus HA, Korosoglou G. Myocardial Perfusion Reserve and Strain-Encoded CMR for Evaluation of Cardiac Allograft Microvasculopathy. JACC Cardiovasc Imaging 2016; 9:255-66. [DOI: 10.1016/j.jcmg.2015.10.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 10/02/2015] [Accepted: 10/07/2015] [Indexed: 10/22/2022]
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Geir Solberg O, Aaberge L, Ragnarsson A, Aas M, Endresen K, Šaltytė Benth J, Gullestad L, Stavem K. Comparison of simplified and comprehensive methods for assessing the index of microvascular resistance in heart transplant recipients. Catheter Cardiovasc Interv 2016; 87:283-90. [PMID: 26525162 DOI: 10.1002/ccd.26283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 08/06/2015] [Accepted: 10/03/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The objectives of the present study were to compare a simplified and a comprehensive method of estimating the index of microvascular resistance (IMR) and assess the changes from 7-11 weeks to 1 year after heart transplant (HTx). BACKGROUND he IMR is specific to the microvasculature and reflects the status of the microcirculation in cardiac patients and can be estimated via a simplified method (IMR(s)) or a comprehensive method (IMR(c)). The calculation for the latter includes coronary wedge pressure and central venous pressure. METHODS Consecutively transplanted patients (n = 48) underwent left and right heart catheterization including physiological evaluation at two time points post-HTx. The agreement between the values of IMR obtained using the IMR(s) and IMR(c) methods were assessed using Bland-Altman analysis. The agreements and differences were assessed using mixed model analysis. RESULTS The mean bias between IMRs and IMRc was 1.3 mm Hg·s (95% limits of agreement: -1.2, 3.8 mm Hg). Between 7-11 weeks and 1 year post-HTx there was a significant decline in IMR(s) values (P = 0.03) but a smaller and statistically nonsignificant decline in IMR(c) values (P = 0.13). The significant difference (P = 0.04) between IMR(c) and IMR(s) 7-11 weeks post-HTx was no longer present at 1 year (P = 0.24). CONCLUSIONS The IMR(s) method resulted in slightly higher IMR estimates and exhibited a somewhat larger change over the 10-month follow-up period than the IMR(c) method. However, the differences between the methods were small and unlikely to be of clinical importance.
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Affiliation(s)
- Ole Geir Solberg
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Institue of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway
| | - Lars Aaberge
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Asgrimur Ragnarsson
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Marit Aas
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Knut Endresen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway.,HØKH, Research Centre, Akershus University Hospital, Lørenskog, Norway
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,K.G. Jebsen Cardiac Research Centre and Centre for Heart Failure Research, Faculty of Medicine, University of Oslo, Norway
| | - Knut Stavem
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway.,HØKH, Research Centre, Akershus University Hospital, Lørenskog, Norway.,Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway
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Broyd CJ, Echavarria-Pinto M, Cerrato E, Escaned J. Evaluation of Microvascular Disease and Clinical Outcomes. Interv Cardiol Clin 2015; 4:443-457. [PMID: 28581931 DOI: 10.1016/j.iccl.2015.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Although coronary microcirculatory dysfunction occurs in numerous cardiac conditions and influences prognosis, it has been largely ignored in clinical practice due to the lack of adequate methods for its assessment. Microcirculatory dysfuntion may result from a variety of causes, including structural remodelling (arterioles or capillaries), dysregulation (paradoxical arteriolar vasoconstriction), hypersensitivity to vasoactive factors or adrenergic drive, and extravascular compression of collapsable elements. Thus, the selection of a method to interrogate coronary microcirculation should be based on the suspected cause of dysfunction. This article reviews such assessment tools and their prognostic information.
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Affiliation(s)
| | | | - Enrico Cerrato
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid 28040, Spain
| | - Javier Escaned
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid 28040, Spain.
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Tona F, Osto E, Famoso G, Previato M, Fedrigo M, Vecchiati A, Perazzolo Marra M, Tellatin S, Bellu R, Tarantini G, Feltrin G, Angelini A, Thiene G, Gerosa G, Iliceto S. Coronary microvascular dysfunction correlates with the new onset of cardiac allograft vasculopathy in heart transplant patients with normal coronary angiography. Am J Transplant 2015; 15:1400-6. [PMID: 25766634 DOI: 10.1111/ajt.13108] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 11/09/2014] [Indexed: 01/25/2023]
Abstract
Coronary microvascular dysfunction is emerging as a strong predictor of outcome in heart transplantation (HT). We assessed the validity of microvascular dysfunction, defined by means of a reduced coronary flow reserve (CFR), as a factor associated with new onset epicardial cardiac allograft vasculopathy (CAV) or death. We studied 105 patients at 4 ± 1 years post-HT with a normal coronary angiography (CA). New onset CAV was assessed by CA. CFR was assessed in the left anterior descending (LAD) coronary artery by transthoracic Doppler echocardiography and calculated as the ratio of hyperaemic to basal blood flow velocity. A CFR ≤ 2.5 was considered abnormal. Epicardial CAV onset or death was assessed during a follow-up of 10 years. New onset CAV was diagnosed in 30 patients (28.6%) (Group A), and the CA was normal in the remaining 75 patients (71.4%) (Group B). Group A had reduced CFR compared with group B (2.4 ± 0.6 vs. 3.2 ± 0.7, p < 0.0001). A CFR ≤ 2.5 was independently associated with a higher probability of new onset CAV (p < 0.0001) and a higher probability of death, regardless of CAV onset (p < 0.01). Microvascular dysfunction is independently associated with the onset of epicardial CAV, and associated with a higher risk of death, regardless of CAV onset.
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Affiliation(s)
- F Tona
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
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Dedieu N, Greil G, Wong J, Fenton M, Burch M, Hussain T. Diagnosis and management of coronary allograft vasculopathy in children and adolescents. World J Transplant 2014; 4:276-293. [PMID: 25540736 PMCID: PMC4274597 DOI: 10.5500/wjt.v4.i4.276] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 08/12/2014] [Accepted: 09/17/2014] [Indexed: 02/05/2023] Open
Abstract
Coronary allograft vasculopathy remains one of the leading causes of death beyond the first year post transplant. As a result of denervation following transplantation, patients lack ischaemic symptoms and presentation is often late when the graft is already compromised. Current diagnostic tools are rather invasive, or in case of angiography, significantly lack sensitivity. Therefore a non-invasive tool that could allow early diagnosis would be invaluable.This paper review the disease form its different diagnosis techniques,including new and less invasive diagnostic tools to its pharmacological management and possible treatments.
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42
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Hirohata A, Yamamoto K, Hirose E, Kobayashi Y, Takafuji H, Sano F, Matsumoto K, Ohara M, Yoshioka R, Takinami H, Ohe T. Nicorandil prevents microvascular dysfunction resulting from PCI in patients with stable angina pectoris: a randomised study. EUROINTERVENTION 2014; 9:1050-6. [PMID: 24457276 DOI: 10.4244/eijv9i9a178] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Nicorandil, an ATP sensitive potassium channel opener, may reduce the incidence of microvascular dysfunction after percutaneous coronary intervention (PCI) by dilating coronary resistance vessels. The aim of the study was evaluation of the impact of the administration of intravenous nicorandil on measuring the index of microcirculatory resistance (IMR) in PCI to patients with stable angina pectoris (SAP). METHODS AND RESULTS Intravascular ultrasound (IVUS), fractional flow reserve (FFR), IMR and blood examination (CK-MB), cardiac troponin I (cTnI) immediately post-PCI (and 24 hours later) were performed in 62 consecutive patients with SAP undergoing PCI. FFR and IMR were measured simultaneously with a single coronary pressure wire. IMR was defined as Pd/coronary flow (or Pd* mean transit time) at peak hyperaemia. Patients were randomised to the control (n=29), or nicorandil group (n=33). In the nicorandil group, nicorandil was intravenously administered as a 6 mg bolus injection just before PCI and as a constant infusion at 6 mg/hour for 24 hours thereafter. All volumetric IVUS parameters and FFR were similar between the two groups both pre- and post-PCI. However, IMR immediately post-PCI and cTnI 24 hours post-PCI were significantly higher in the control group compared to the nicorandil group (IMR: 25.4±12.1 vs. 17.9±9.1 units, and cTnI: 0.21±0.13 vs. 0.12±0.08 ng/mL, for control vs. nicorandil). The incidence for cTnI elevation more than fivefold the normal range (>0.20 ng/mL) was significantly larger in the control group than in the nicorandil group (41% vs. 12%, p<0.01). Additionally, the control group showed a closer correlation between plaque volume reduction during stenting as assessed by volumetric IVUS, and cTnI elevation than the nicorandil group (r=0.55 vs. 0.42, p<0.001 for control vs. nicorandil). CONCLUSIONS In patients undergoing successful coronary stenting for stable angina, administration of nicorandil is associated with reduced microvascular dysfunction induced by PCI.
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Mc Ardle BA, Davies RA, Chen L, Small GR, Ruddy TD, Dwivedi G, Yam Y, Haddad H, Mielniczuk LM, Stadnick E, Hessian R, Guo A, Beanlands RS, deKemp RA, Chow BJW. Prognostic value of rubidium-82 positron emission tomography in patients after heart transplant. Circ Cardiovasc Imaging 2014; 7:930-7. [PMID: 25182366 DOI: 10.1161/circimaging.114.002184] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiac allograft vasculopathy is a key prognostic determinant after heart transplant. Detection and risk stratification of patients with cardiac allograft vasculopathy are problematic. Positron emission tomography using rubidium-82 allows quantification of absolute myocardial blood flow and may have utility for risk stratification in this population. METHODS AND RESULTS Patients with a history of heart transplant undergoing dipyridamole rubidium-82 positron emission tomography were prospectively enrolled. Myocardial perfusion and left ventricular ejection fraction were recorded. Absolute flow quantification at rest and after dipyridamole stress as well as the ratio of mean global flow at stress and at rest, termed myocardial flow reserve, were calculated. Patients were followed for all-cause death, acute coronary syndrome, and heart failure hospitalization. A total of 140 patients (81% men; median age, 62 years; median follow-up, 18.2 months) were included. There were 14 events during follow-up (9 deaths, 1 acute coronary syndrome, and 4 heart failure admissions). In addition to baseline clinical variables (estimated glomerular filtration rate, previously documented cardiac allograft vasculopathy), relative perfusion defects, mean myocardial flow reserve, and mean stress myocardial blood flow were significant predictors of adverse outcome. CONCLUSIONS Abnormalities on rubidium-82 positron emission tomography were predictors of adverse events in heart transplant patients. Larger prospective studies are required to confirm these findings.
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Affiliation(s)
- Brian A Mc Ardle
- From the Division of Cardiology, Department of Medicine (B.A.M.A., R.A.D., G.R.S., T.D.R., G.D., Y.Y., H.H., L.M.M., E.S., R.H., R.S.B., B.J.W.C.), National Cardiac PET Center (B.A.M.A., R.A.D., T.D.R., R.H., A.G., R.S.B., R.A.d., B.J.W.C.), and Division of Cardiology, Department of Medicine, Cardiovascular Research Methods Center (L.C.), University of Ottawa Heart Institute. Ottawa, Canada
| | - Ross A Davies
- From the Division of Cardiology, Department of Medicine (B.A.M.A., R.A.D., G.R.S., T.D.R., G.D., Y.Y., H.H., L.M.M., E.S., R.H., R.S.B., B.J.W.C.), National Cardiac PET Center (B.A.M.A., R.A.D., T.D.R., R.H., A.G., R.S.B., R.A.d., B.J.W.C.), and Division of Cardiology, Department of Medicine, Cardiovascular Research Methods Center (L.C.), University of Ottawa Heart Institute. Ottawa, Canada
| | - Li Chen
- From the Division of Cardiology, Department of Medicine (B.A.M.A., R.A.D., G.R.S., T.D.R., G.D., Y.Y., H.H., L.M.M., E.S., R.H., R.S.B., B.J.W.C.), National Cardiac PET Center (B.A.M.A., R.A.D., T.D.R., R.H., A.G., R.S.B., R.A.d., B.J.W.C.), and Division of Cardiology, Department of Medicine, Cardiovascular Research Methods Center (L.C.), University of Ottawa Heart Institute. Ottawa, Canada
| | - Gary R Small
- From the Division of Cardiology, Department of Medicine (B.A.M.A., R.A.D., G.R.S., T.D.R., G.D., Y.Y., H.H., L.M.M., E.S., R.H., R.S.B., B.J.W.C.), National Cardiac PET Center (B.A.M.A., R.A.D., T.D.R., R.H., A.G., R.S.B., R.A.d., B.J.W.C.), and Division of Cardiology, Department of Medicine, Cardiovascular Research Methods Center (L.C.), University of Ottawa Heart Institute. Ottawa, Canada
| | - Terrence D Ruddy
- From the Division of Cardiology, Department of Medicine (B.A.M.A., R.A.D., G.R.S., T.D.R., G.D., Y.Y., H.H., L.M.M., E.S., R.H., R.S.B., B.J.W.C.), National Cardiac PET Center (B.A.M.A., R.A.D., T.D.R., R.H., A.G., R.S.B., R.A.d., B.J.W.C.), and Division of Cardiology, Department of Medicine, Cardiovascular Research Methods Center (L.C.), University of Ottawa Heart Institute. Ottawa, Canada
| | - Girish Dwivedi
- From the Division of Cardiology, Department of Medicine (B.A.M.A., R.A.D., G.R.S., T.D.R., G.D., Y.Y., H.H., L.M.M., E.S., R.H., R.S.B., B.J.W.C.), National Cardiac PET Center (B.A.M.A., R.A.D., T.D.R., R.H., A.G., R.S.B., R.A.d., B.J.W.C.), and Division of Cardiology, Department of Medicine, Cardiovascular Research Methods Center (L.C.), University of Ottawa Heart Institute. Ottawa, Canada
| | - Yeung Yam
- From the Division of Cardiology, Department of Medicine (B.A.M.A., R.A.D., G.R.S., T.D.R., G.D., Y.Y., H.H., L.M.M., E.S., R.H., R.S.B., B.J.W.C.), National Cardiac PET Center (B.A.M.A., R.A.D., T.D.R., R.H., A.G., R.S.B., R.A.d., B.J.W.C.), and Division of Cardiology, Department of Medicine, Cardiovascular Research Methods Center (L.C.), University of Ottawa Heart Institute. Ottawa, Canada
| | - Haissam Haddad
- From the Division of Cardiology, Department of Medicine (B.A.M.A., R.A.D., G.R.S., T.D.R., G.D., Y.Y., H.H., L.M.M., E.S., R.H., R.S.B., B.J.W.C.), National Cardiac PET Center (B.A.M.A., R.A.D., T.D.R., R.H., A.G., R.S.B., R.A.d., B.J.W.C.), and Division of Cardiology, Department of Medicine, Cardiovascular Research Methods Center (L.C.), University of Ottawa Heart Institute. Ottawa, Canada
| | - Lisa M Mielniczuk
- From the Division of Cardiology, Department of Medicine (B.A.M.A., R.A.D., G.R.S., T.D.R., G.D., Y.Y., H.H., L.M.M., E.S., R.H., R.S.B., B.J.W.C.), National Cardiac PET Center (B.A.M.A., R.A.D., T.D.R., R.H., A.G., R.S.B., R.A.d., B.J.W.C.), and Division of Cardiology, Department of Medicine, Cardiovascular Research Methods Center (L.C.), University of Ottawa Heart Institute. Ottawa, Canada
| | - Ellamae Stadnick
- From the Division of Cardiology, Department of Medicine (B.A.M.A., R.A.D., G.R.S., T.D.R., G.D., Y.Y., H.H., L.M.M., E.S., R.H., R.S.B., B.J.W.C.), National Cardiac PET Center (B.A.M.A., R.A.D., T.D.R., R.H., A.G., R.S.B., R.A.d., B.J.W.C.), and Division of Cardiology, Department of Medicine, Cardiovascular Research Methods Center (L.C.), University of Ottawa Heart Institute. Ottawa, Canada
| | - Renee Hessian
- From the Division of Cardiology, Department of Medicine (B.A.M.A., R.A.D., G.R.S., T.D.R., G.D., Y.Y., H.H., L.M.M., E.S., R.H., R.S.B., B.J.W.C.), National Cardiac PET Center (B.A.M.A., R.A.D., T.D.R., R.H., A.G., R.S.B., R.A.d., B.J.W.C.), and Division of Cardiology, Department of Medicine, Cardiovascular Research Methods Center (L.C.), University of Ottawa Heart Institute. Ottawa, Canada
| | - Ann Guo
- From the Division of Cardiology, Department of Medicine (B.A.M.A., R.A.D., G.R.S., T.D.R., G.D., Y.Y., H.H., L.M.M., E.S., R.H., R.S.B., B.J.W.C.), National Cardiac PET Center (B.A.M.A., R.A.D., T.D.R., R.H., A.G., R.S.B., R.A.d., B.J.W.C.), and Division of Cardiology, Department of Medicine, Cardiovascular Research Methods Center (L.C.), University of Ottawa Heart Institute. Ottawa, Canada
| | - Rob S Beanlands
- From the Division of Cardiology, Department of Medicine (B.A.M.A., R.A.D., G.R.S., T.D.R., G.D., Y.Y., H.H., L.M.M., E.S., R.H., R.S.B., B.J.W.C.), National Cardiac PET Center (B.A.M.A., R.A.D., T.D.R., R.H., A.G., R.S.B., R.A.d., B.J.W.C.), and Division of Cardiology, Department of Medicine, Cardiovascular Research Methods Center (L.C.), University of Ottawa Heart Institute. Ottawa, Canada
| | - Robert A deKemp
- From the Division of Cardiology, Department of Medicine (B.A.M.A., R.A.D., G.R.S., T.D.R., G.D., Y.Y., H.H., L.M.M., E.S., R.H., R.S.B., B.J.W.C.), National Cardiac PET Center (B.A.M.A., R.A.D., T.D.R., R.H., A.G., R.S.B., R.A.d., B.J.W.C.), and Division of Cardiology, Department of Medicine, Cardiovascular Research Methods Center (L.C.), University of Ottawa Heart Institute. Ottawa, Canada
| | - Benjamin J W Chow
- From the Division of Cardiology, Department of Medicine (B.A.M.A., R.A.D., G.R.S., T.D.R., G.D., Y.Y., H.H., L.M.M., E.S., R.H., R.S.B., B.J.W.C.), National Cardiac PET Center (B.A.M.A., R.A.D., T.D.R., R.H., A.G., R.S.B., R.A.d., B.J.W.C.), and Division of Cardiology, Department of Medicine, Cardiovascular Research Methods Center (L.C.), University of Ottawa Heart Institute. Ottawa, Canada.
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Wu Z, Ye F, You W, Zhang J, Xie D, Chen S. Microcirculatory significance of periprocedural myocardial necrosis after percutaneous coronary intervention assessed by the index of microcirculatory resistance. Int J Cardiovasc Imaging 2014; 30:995-1002. [DOI: 10.1007/s10554-014-0444-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 05/07/2014] [Indexed: 11/28/2022]
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Sade LE, Eroğlu S, Yüce D, Bircan A, Pirat B, Sezgin A, Aydınalp A, Müderrisoğlu H. Follow-Up of Heart Transplant Recipients with Serial Echocardiographic Coronary Flow Reserve and Dobutamine Stress Echocardiography to Detect Cardiac Allograft Vasculopathy. J Am Soc Echocardiogr 2014; 27:531-9. [DOI: 10.1016/j.echo.2014.01.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Indexed: 01/08/2023]
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Affiliation(s)
- Yuhei Kobayashi
- Division of Cardiovascular Medicine, Stanford University Medical Center
| | - William F Fearon
- Division of Cardiovascular Medicine, Stanford University Medical Center
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47
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Solberg OG, Ragnarsson A, Kvarsnes A, Endresen K, Kongsgård E, Aakhus S, Gullestad L, Stavem K, Aaberge L. Reference interval for the index of coronary microvascular resistance. EUROINTERVENTION 2014; 9:1069-75. [DOI: 10.4244/eijv9i9a181] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Miller CA, Sarma J, Naish JH, Yonan N, Williams SG, Shaw SM, Clark D, Pearce K, Stout M, Potluri R, Borg A, Coutts G, Chowdhary S, McCann GP, Parker GJM, Ray SG, Schmitt M. Multiparametric cardiovascular magnetic resonance assessment of cardiac allograft vasculopathy. J Am Coll Cardiol 2013; 63:799-808. [PMID: 24355800 DOI: 10.1016/j.jacc.2013.07.119] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 06/21/2013] [Accepted: 07/15/2013] [Indexed: 11/17/2022]
Abstract
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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Affiliation(s)
- Christopher A Miller
- North 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.
| | - Jaydeep Sarma
- North West Heart Centre and Transplant Centre, University Hospital of South Manchester, Wythenshawe Hospital, Manchester, United Kingdom; Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Josephine H Naish
- Centre for Imaging Sciences and Biomedical Imaging Institute, University of Manchester, Manchester, United Kingdom
| | - Nizar Yonan
- North West Heart Centre and Transplant Centre, University Hospital of South Manchester, Wythenshawe Hospital, Manchester, United Kingdom; Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Simon G Williams
- North West Heart Centre and Transplant Centre, University Hospital of South Manchester, Wythenshawe Hospital, Manchester, United Kingdom; Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Steven M Shaw
- North West Heart Centre and Transplant Centre, University Hospital of South Manchester, Wythenshawe Hospital, Manchester, United Kingdom; Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - David Clark
- Alliance Medical Cardiac MRI Unit, Wythenshawe Hospital, Manchester, United Kingdom
| | - Keith Pearce
- North West Heart Centre and Transplant Centre, University Hospital of South Manchester, Wythenshawe Hospital, Manchester, United Kingdom
| | - Martin Stout
- North West Heart Centre and Transplant Centre, University Hospital of South Manchester, Wythenshawe Hospital, Manchester, United Kingdom
| | - Rahul Potluri
- North 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
| | - Alex Borg
- North West Heart Centre and Transplant Centre, University Hospital of South Manchester, Wythenshawe Hospital, Manchester, United Kingdom
| | - Glyn Coutts
- Christie Medical Physics and Engineering, Christie Hospital, Manchester, United Kingdom
| | - Saqib Chowdhary
- North West Heart Centre and Transplant Centre, University Hospital of South Manchester, Wythenshawe Hospital, Manchester, United Kingdom; Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Gerry P McCann
- NIHR Leicester Cardiovascular Biomedical Research Unit and Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Geoffrey J M Parker
- Centre for Imaging Sciences and Biomedical Imaging Institute, University of Manchester, Manchester, United Kingdom
| | - Simon G Ray
- North West Heart Centre and Transplant Centre, University Hospital of South Manchester, Wythenshawe Hospital, Manchester, United Kingdom; Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Matthias Schmitt
- North West Heart Centre and Transplant Centre, University Hospital of South Manchester, Wythenshawe Hospital, Manchester, United Kingdom; Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
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Calé R, Rebocho MJ, Aguiar C, Almeida M, Queiroz e Melo J, Silva JA. Diagnosis, prevention and treatment of cardiac allograft vasculopathy. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.repce.2012.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Calé R, Rebocho MJ, Aguiar C, Almeida M, Queiroz E Melo J, Silva JA. [Diagnosis, prevention and treatment of cardiac allograft vasculopathy]. Rev Port Cardiol 2012; 31:721-30. [PMID: 22999223 DOI: 10.1016/j.repc.2012.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 06/14/2012] [Indexed: 10/27/2022] Open
Abstract
The major limitation of long-term survival after cardiac transplantation is allograft vasculopathy, which consists of concentric and diffuse intimal hyperplasia. The disease still has a significant incidence, estimated at 30% five years after cardiac transplantation. It is a clinically silent disease and so diagnosis is a challenge. Coronary angiography supplemented by intravascular ultrasound is the most sensitive diagnostic method. However, new non-invasive diagnostic techniques are likely to be clinically relevant in the future. The earliest possible diagnosis is essential to prevent progression of the disease and to improve its prognosis. A new nomenclature for allograft vasculopathy has been published in July 2010, developed by the International Society for Heart and Lung Transplantation (ISHLT), establishing a standardized definition. Simultaneously, the ISHLT published new guidelines standardizing the diagnosis and management of cardiac transplant patients. This paper reviews contemporary concepts in the pathophysiology, diagnosis, prevention and treatment of allograft vasculopathy, highlighting areas that are the subject of ongoing research.
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Affiliation(s)
- Rita Calé
- Departamento de Cardiologia e Cirurgia Cardiotorácica, Hospital Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal.
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