Clinical implementation of coronary computed tomography angiography for routine detection of cardiac allograft vasculopathy in heart transplant patients

Abstract

Cardiac allograft vasculopathy (CAV) is an accelerated form of coronary artery disease that affects long-term outcomes in heart transplant (HTx) patients. We prospectively evaluated the feasibility of coronary computed tomography angiography (CCTA) for the detection of CAV during clinical implementation at our center. All consecutive HTx patients >4 years posttransplant were actively converted from myocardial perfusion imaging to CCTA for the annual assessment of CAV. Between February 2018 and May 2019, 129/172 (75%) HTx patients underwent a CCTA. Renal impairment (n = 21/43) was the most frequent reason for patients could not undergo CCTA. CCTA image quality was good-excellent in 118/129 (92%) patients, and the radiation dose was 2.1 (1.6-2.8) mSv. CCTA showed obstructive CAV in 19/129 (15%) patients. Thirteen (10%) patients underwent additional tests, of which 8 patients underwent coronary revascularization within 90 days of CCTA. After 1 year, 3 additional coronary angiograms were performed, resulting in one revascularization in a patient with known severe CAV who developed ventricular tachycardia. One myocardial infarction after coronary stenting and 2 non-cardiac deaths were observed. CCTA can be successfully implemented for routine detection of CAV with good image quality and low radiation dose. CCTA allows CAV evaluation with the limited need for additional invasive testing.

Cardiac allograft vasculopathy and donor age affecting permanent pacemaker implantation after heart transplantation

“…12 Since March 2018, coronary computed tomographies are performed instead of myocardial perfusion imaging in suitable patients. 18 Again, when the computed tomography result was abnormal, an invasive coronary angiography was performed to confirm the CAV diagnosis. In case a patient developed a bradyarrythmia, an invasive coronary angiography and an endomyocardial biopsy were performed to exclude CAV and/or rejection before PM implantation.…”

Epicardial fat volume is related to the degree of cardiac allograft vasculopathy

“…All adult patients that were seen at our outpatient clinic and were more than 4 years post-HT who underwent a CT for annual/biannual CAV screening were included in the study. Patients with an impaired renal function (estimated glomerular filtration rate < 45 mL/min/1.73 m 2 before March 15, 2018, or < 30 mL/min/1.73 m 2 after March 15, 2018, due to a change in the contrast nephropathy prevention protocol at our institution) or iodine allergy were excluded from CCTA [6]. All first CT scans performed between February 2018 and June 2020 were included.…”

“…Despite substantial drawbacks, such as high radiation dose and peri-procedural complications, the screening procedure is advised to be done with coronary angiography [2]. To overcome these drawbacks, at our institution, we successfully implemented coronary computed tomography angiographies (CCTAs) for routine screening of CAV in 2018 [6,7]. Because CT scans contain much more information, beyond only luminal stenosis, which is assessed with invasive coronary angiography, CAV can be detected in an earlier stage of the disease [8].…”

Multimodality Imaging to Detect Rejection, and Cardiac Allograft Vasculopathy in Pediatric Heart Transplant Recipients—An Illustrative Review

“…CT coronary angiography (CTCA) has higher sensitivity and specificity for diagnosing CAV compared to stress echocardiography. It has been used in adults for routine detection of CVA with good image quality and low radiation dose [42]. With photon-counting CT, we are entering a new era that decreases radiation dose and less need for a contrast agent for CTCA to detect CAV early in the disease process [43].…”