Institutional Practice and Opinion on Cardiac Allograft Vasculopathy Surveillance

Abstract

<h3>Purpose</h3> Cardiac allograft vasculopathy (CAV) after heart transplantation (HT) is common and a challenging complication, which compromises long term patient and graft outcomes. We conducted a survey to evaluate institutional practice and clinician views on CAV screening. <h3>Methods</h3> ISHLT members were invited to participate in a 16-question online survey. <h3>Results</h3> There were 72 respondents (cardiologist 86%, surgeon 6%, nurse 6%, other 2%) predominantly from North America (61%) and Europe (21%) with 47%, 26% and 26% in practice <i>></i>10, 5-10 and <5 years, respectively. All institutions routinely screen for CAV, generally lifelong (76%). Screening frequency varies: 42% annually, 28% 1-2 yearly, 7% 2 yearly, 24% other. Invasive coronary angiography (ICA) is undertaken by 96% of centers and adjunctive intracoronary imaging by over half (Figure). Stress echo (88%), SPECT (78%) and coronary CT (81%) are readily accessible while perfusion PET (49%) and MRI (56%) are less available. Noninvasive imaging for CAV is performed at most centers but the modality used varies for reasons such as center expertise (43%), patient safety/comfort (40%), supporting data (19%) and cost (17%). All clinicians believe CAV screening is important and 79% monitor patients lifelong. The majority (92%) are comfortable performing ICA every 1-2 years but for differing duration post HT: 50% lifelong, 10% to 10 years, 18% to 5 years, 6% to 2 years. Most clinicians (71%) are comfortable with noninvasive surveillance, including at any time (26%), after 1 year (14%) or 5 years (17%) post HT. There is no preferred noninvasive imaging and 49% of clinicians are comfortable using any available modality for CAV. <h3>Conclusion</h3> The ideal surveillance approach for CAV is unclear. There is variability in institutional practice and opinion on screening frequency, invasive vs. noninvasive testing, intracoronary imaging and preferred noninvasive modality. Our results indicate clinical equipoise and a clear need for high quality comparative data to guide optimal CAV screening.