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.
Highlights
Cardiac transplant-related arteriopathy remains a leading cause of morbidity and mortality in heart transplant recipients with one in 3 patients developing cardiac allograft vasculopathy (CAV) in the first 5 years after heart transplantation [1]
A grading system based on coronary angiography is recommended by the international society of heart and lung transplantation (ISHLT) to evaluate the severity and extent of Cardiac allograft vasculopathy (CAV) [4]
Heart transplant recipients were included at time of their yearly annual surveillance coronary angiography, and patients with angiograms amenable for three-dimensional vessel reconstruction were included in the study
Summary
Cardiac transplant-related arteriopathy remains a leading cause of morbidity and mortality in heart transplant recipients with one in 3 patients developing cardiac allograft vasculopathy (CAV) in the first 5 years after heart transplantation [1]. Coronary angiography lacks the resolution to diagnose early as well as diffuse stages of CAV, a limitation that has partly been overcome by more recent imaging techniques, such as intravascular ultrasound (IVUS) [5, 6] On his turn, IVUS findings are unable to assess the functional significance of vascular disease. 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). E 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. Conclusion. e 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. erefore, we speculate that vFFR may be useful in risk stratification after HTx
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