Abstract
ObjectivesTo associate coronary wall volume and composition, derived from coronary computed tomography angiography (CTA), with cardiac allograft vasculopathy (CAV) detected on invasive coronary angiography (ICA) in heart-transplanted (HTX) patients.MethodsWe included consecutive adults who received ICA and coronary CTA for evaluation of CAV ≥ 10 months after HTX. In all coronary segments, we assessed lumen and wall volumes and segmental length, calculated volume-length ratio (VLR) (volumes indexed by segmental length; mm3/mm), wall burden (WB) (wall/wall + lumen volumes; %), and assessed proportions of calcified, fibrotic, fibro-fatty, and low-attenuation tissue (%) in coronary wall. We rendered independent CTA measures associated with CAV by ICA, tested their discriminatory capacity, and assessed concordance between CTA and ICA.ResultsAmong 50 patients (84% men; 53.6 ± 11.9 years), we analyzed 632 coronary segments. Mean interval between HTX and CTA was 6.7 ± 4.7 years and between ICA and CTA 1 (0–1) day. Segmental VLR, WB, and proportion of fibrotic tissue were independently associated with CAV (OR = 1.06–1.27; p ≤ 0.002), reaching a high discriminatory capacity (combination of all three: AUC = 0.84; 95%CI, 0.75–0.90). Concordance between CTA and ICA was higher in advanced CAV (88%) compared with that in none (37%) and mild (19%) CAV. Discordance was primarily driven by a large number of segments with coronary wall changes on CTA but without luminal stenoses on ICA (177/591; 25%).ConclusionCTA-derived coronary wall VLR, WB, and the proportion of fibrotic tissue are independent markers of CAV. Combination of these three parameters may aid the detection of early CAV not detected by ICA, the current standard of care.Key Points• Coronary CTA detects CAV in HTX patients.• Coronary wall volume-length ratio, wall burden, and proportion of fibrotic tissue are independently associated with CAV.• In contrast to ICA, coronary CTA may identify the early stages of CAV.
Highlights
Induced by immune and nonimmune triggers, cardiac allograft vasculopathy (CAV) reaches a high incidence of up to 40% in the first 5–8 years after heart transplantation (HTX) and represents the leading cause of graft failure and death among HTX patients [1]
Early CAV is characterized by vascular fibroproliferation and diffuse coronary wall changes without coronary stenosis, unlike advanced CAV, which presents with constrictive remodeling and coronary stenosis [4,5,6,7]
This study had two major findings: (1) computed tomography angiography (CTA)-derived coronary wall volume-length ratio, wall burden, and proportion of fibrotic tissue were independently associated with CAV, and (2) concordance between CTA and invasive coronary angiography (ICA) was high in advanced CAV, while discordance was driven predominantly by distal coronary segments with changes of coronary wall on CTA but without CAV on ICA
Summary
Induced by immune and nonimmune triggers, cardiac allograft vasculopathy (CAV) reaches a high incidence of up to 40% in the first 5–8 years after heart transplantation (HTX) and represents the leading cause of graft failure and death among HTX patients [1]. HTX patients should be frequently monitored by invasive coronary angiography (ICA) to detect CAV (class Ia recommendation [2, 3]). Early CAV is characterized by vascular fibroproliferation and diffuse coronary wall changes without coronary stenosis, unlike advanced CAV, which presents with constrictive remodeling and coronary stenosis [4,5,6,7]. While ICA examines merely the coronary lumen, it focuses on stenosis and may miss early stages of CAV which occur as changes of the coronary wall. Supplemental invasive intravascular ultrasound (IVUS) can assess the coronary wall and increase sensitivity [3, 6, 8, 9]. IVUS is accompanied by an increased risk of severe complications (up to 4%), including coronary spasm, acute occlusions, embolism, arrhythmia, dissection, and acute thrombosis [8]
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