Evaluation of coronary allograft vasculopathy using multi-detector row computed tomography: a systematic review.
01 Feb 2012-European Journal of Cardio-Thoracic Surgery (Oxford University Press)-Vol. 41, Iss: 2, pp 415-422
TL;DR: The high sensitivity and NPV of MDCT suggest that it may be a useful, noninvasive screening tool to rule out CAV.
Abstract: Summary Coronary allograft vasculopathy (CAV) is a significant cause of morbidity and mortality after cardiac transplantation and requires frequent surveillance with catheter-based coronary angiography (CCA). Multi-detector row computed tomography (MDCT) has been shown to be effective in assessing atherosclerosis in native coronary arteries. This article systematically reviews the literature to determine the accuracy of MDCT in CAVassessment. An English-language literature search was performed using EMBASE, OVID, PubMed, and Cochrane Library databases. Studies that directly compared MDCTwith CCA and/or IVUS for the detection of coronary artery stenosis or significant intimal thickening in cardiac transplant patients were analyzed. Data were pooled to obtain weighted sensitivities, specificities, and diagnostic accuracies. Negative and positive predictive values (NPV/PPV) were calculated. A total of seven studies with a sum of 272 patients were included in this review. There were three studies examining 16-slice MDCTand four studies looking at 64-slice MDCT in CAV. Using per-segment analysis, MDCTassessed between 91% and 96% of all coronary segments when evaluating for stenosis. Pooled estimates for sensitivity and specificity for MDCTranged from 82% to 89% and 89% to 99%, respectively, while NPV was 99%. Per-patient analysis revealed a sensitivity of 87—100% and NPV of 96—100%. PPV was less than 50% for 64slice MDCT in both per-segment and per-patient analysis. When compared with IVUS, MDCT had a sensitivity of 74—96% and specificity of 88—92% in assessment of intimal thickening. NPVand PPV were 80—81% and 84—98%, respectively. The high sensitivity and NPV of MDCTsuggest that it may be a useful, noninvasive screening tool to rule out CAV. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
Citations
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TL;DR: CCTA using currently available technology is a reliable noninvasive imaging alternative to coronary angiography with an excellent sensitivity, specificity, and NPV for the detection of CAV.
112 citations
TL;DR: The purpose of this guideline is to assist clinicians and other health professionals in the use of cardiac CT for diagnosis and treatment of heart diseases, especially in patients at high risk or suspected of heart disease.
Abstract: The development of cardiac CT has provided a non-invasive alternative to echocardiography, exercise electrocardiogram, and invasive angiography and cardiac CT continues to develop at an exponential speed even now. The appropriate use of cardiac CT may lead to improvements in the medical performances of physicians and can reduce medical costs which eventually contribute to better public health. However, until now, there has been no guideline regarding the appropriate use of cardiac CT in Korea. We intend to provide guidelines for the appropriate use of cardiac CT in heart diseases based on scientific data. The purpose of this guideline is to assist clinicians and other health professionals in the use of cardiac CT for diagnosis and treatment of heart diseases, especially in patients at high risk or suspected of heart disease.
61 citations
TL;DR: It is therefore of utmost importance that interventional cardiologists become familiar with image interpretation and up-to-date regarding several CCTA features, taking advantage of this information in planning the procedure, ultimately leading to improvement in patient outcomes.
Abstract: In recent years, coronary CT angiography (CCTA) has become a widely adopted technique, not only due to its high diagnostic accuracy, but also to the fact that CCTA provides a comprehensive evaluation of the total (obstructive and non-obstructive) coronary atherosclerotic burden. More recently, this technique has become mature, with a large body of evidence addressing its prognostic validation. In addition, CT angiography has moved from the field of ‘imagers’ and clinicians and entered the interventional cardiology arena, aiding in the planning of both coronary and structural heart interventions, being transcatheter aortic valve implantation one of its most successful examples. It is therefore of utmost importance that interventional cardiologists become familiar with image interpretation and up-to-date regarding several CTA features, taking advantage of this information in planning the procedure, ultimately leading to improvement in patient outcomes. On the other hand, the increasing use of CCTA as a gatekeeper for invasive coronary angiography is expected to lead to an increase in the ratio of interventional to diagnostic procedures and significant changes in the daily cath-lab routine. In a foreseeable future, cath-labs will probably offer an invasive procedure only to patients expected to undergo an intervention, perhaps becoming in this change true interventional-labs.
15 citations
TL;DR: MCP-1, RANTES, and fractalkine probably promote instability of coronary atherosclerotic plaque.
Abstract: Our aim was to investigate the role of chemokines in promoting instability of coronary atherosclerotic plaques and the underlying molecular mechanism. Coronary angiography and intravascular ultrasound (IVUS) were performed in 60 stable angina pectoris (SAP) patients and 60 unstable angina pectoris (UAP) patients. The chemotactic activity of monocytes in the 2 groups of patients was examined in Transwell chambers. High-sensitivity C-reactive protein (hs-CRP), monocyte chemoattractant protein-1 (MCP-1), regulated on activation in normal T-cell expressed and secreted (RANTES), and fractalkine in serum were examined with ELISA kits, and expression of MCP-1, RANTES, and fractalkine mRNA was examined with real-time PCR. In the SAP group, 92 plaques were detected with IVUS. In the UAP group, 96 plaques were detected with IVUS. The plaques in the UAP group were mainly lipid 51.04% (49/96) and the plaques in the SAP group were mainly fibrous 52.17% (48/92). Compared with the SAP group, the plaque burden and vascular remodeling index in the UAP group were significantly greater than in the SAP group (P<0.01). Chemotactic activity and the number of mobile monocytes in the UAP group were significantly greater than in the SAP group (P<0.01). Concentrations of hs-CRP, MCP-1, RANTES, and fractalkine in the serum of the UAP group were significantly higher than in the serum of the SAP group (P<0.05 or P<0.01), and expression of MCP-1, RANTES, and fractalkine mRNA was significantly higher than in the SAP group (P<0.05). MCP-1, RANTES, and fractalkine probably promote instability of coronary atherosclerotic plaque.
10 citations
Additional excerpts
...Complications include occlusion, rupture, and hemorrhage (2,3)....
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TL;DR: This work intends to provide guidelines for the appropriate use of cardiac CT in heart diseases based on scientific data to assist the clinicians and other health professionals when using cardiac CT for diagnosis and treatments of heart diseases in Korea.
Abstract: This work is supported by a Grant from National Strategic Coordiating Center for Clinical Research, Republic of Korea (A102065). Heart disease is one of the leading causes of deaths in Korea, along with malignant neoplasms and cerebrovascular diseases. The proper diagnosis and management for patients with suspected heart diseases should be warranted for the public health care. Advances in CT technology have allowed detailed images of the heart to be obtained, which enable evaluations not only of the coronary arteries but also of other cardiac structures. Currently, the latest multi-detector CT machines are widespread around Korea. The appropriate use of cardiac CT may lead to improvements of the physicians’ medical performances and to reduce medical costs which eventually contribute to promotions of public health. However, until now, there has been no guidelines regarding the appropriate use of cardiac CT in Korea. We intend to provide guidelines for the appropriate use of cardiac CT in heart diseases based on scientific data. The purpose of this guideline is to assist the clinicians and other health professionals when using cardiac CT for diagnosis and treatments of heart diseases.
7 citations
References
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TL;DR: MSCT with its high specificity and high negative predictive value allows the exclusion of significant coronary artery vasculopathy in evaluable patients from the clinical point of view, this might spare additional invasive coronary angiography in heart transplant patients.
Abstract: Background Post-transplant follow-up of heart transplant patients consists of repeated coronary angiography, which is associated with high costs, discomfort and risk. We sought to determine whether multislice computed tomography (MSCT) permits the exclusion or progression of coronary artery disease in heart transplant patients. Methods MSCT scanning (Philips CT MX 8000 IDT) and invasive coronary angiography were performed on 66 consecutive heart transplant patients. One hundred milliliters of non-ionic iodinated contrast medium was applied for CT angiography. For MSCT analysis, coronary arteries and side branches with a diameter ≥1.5 mm were assessed for the presence of luminal narrowing of >70%. MSCT results were compared with those of quantitative coronary angiography analysis. Results Ten patients (17%) had one significant stenosis, whereas 3 patients (5%) had 2-vessel disease and none had 3-vessel disease. MSCT was performed successfully on 60 patients enrolled in our analysis. Forty-two of 44 patients (95%) who were estimated to be fully evaluable for MSCT were correctly classified. On per-segment–based analysis, sensitivity, specificity and positive and negative predictive values were 59%, 94%, 91% and 99.43%, respectively. After exclusion of unevaluable segments, sensitivity and specificity increased to 71% and 99.86%, respectively. On per-patient–based analysis, sensitivity, specificity and positive and negative predictive values were 88%, 97%, 88% and 97%, respectively, in evaluable transplant recipients. Conclusions MSCT with its high specificity and high negative predictive value allows the exclusion of significant coronary artery vasculopathy in evaluable patients. From the clinical point of view, this might spare additional invasive coronary angiography in heart transplant patients.
34 citations
"Evaluation of coronary allograft va..." refers methods in this paper
...Significant stenosis was defined by the presence of a >50% or ≥50% obstructive lesion [9–14] in every study except one where >70% obstruction was used as a cutoff [15]....
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TL;DR: MDCT, especially 64-detector CT, is feasible for detecting CAV, whereas MRCA currently shows limited sensitivity, whereas MDCT has shown no false positives.
Abstract: Background: Cardiac allograft vasculopathy (CAV) is a major complication that limits the long-term survival of recipients of heart transplants. In the present study the feasibility of 2 noninvasive approaches for detecting CAV (multidetector computed tomography (MDCT) and whole-heart magnetic resonance coronary angiography (MRCA)) was compared with conventional coronary angiography (CCAG). Methods and Results: Of 22 heart transplant recipients who underwent CCAG screening, 13 had only MDCT, 16 had only MRCA, and 7 had both noninvasive modalities. The coronary arterial tree was divided into 9 segments. Detection of vasculopathy by coronary segments was compared between 16-/64-detector computed tomography (CT) or MRCA and CCAG. The sensitivity of both 16- and 64-detector CT for diagnosing CAV was 69.6%, and specificity was 96.8%. The sensitivity and specificity by 64-detector CT alone were 90.0% and 97.5%, respectively; its positive and negative predictive values were 81.8% and 98.7% respectively. For MRCA, sensitivity was 60%, specificity, 100%, positive predictive value, 100% and negative predictive value, 92.2%. MRCA showed no false positives. Conclusions: MDCT, especially 64-detector CT, is feasible for detecting CAV, whereas MRCA currently shows limited sensitivity. (Circ J 2010; 74: 946 - 953)
31 citations
Additional excerpts
...In studies that compared the efficacy of MDCT in assessing the degree of luminal stenosis to QCA, Pearson correlation coefficients ranged from moderate to excellent (r = 0.64–0.89), suggesting good correlation between both modalities [10–12]....
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...Only two investigations did not corroborate qualitative CCA assessment of coronary stenosis with quantitative coronary angiography (QCA) [9,11]....
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...CAV: coronary allograft vasculopathy; CIN: contrast-induced nephropathy; CCA: catheter-based coronary angiography; DSCT: dual-source computed tomography; IVUS: intravascular ultrasound; MDCT: multi-detector row computed tomography; NPV: negative predictive value; PPV: positive predictive value; QCA: quantitative coronary angiography....
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...quantitative coronary angiography (QCA) [9,11]....
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TL;DR: Coronary CT permits acceptable image quality in more than 90% of patients with chest pain, and patients with multiple risk factors are more likely to have impaired image quality or non-evaluable coronary segments.
26 citations
"Evaluation of coronary allograft va..." refers background in this paper
...Even with the improved temporal resolution of 64-slice scanners, heart rate has been shown to correlate inversely with image quality by causing motion artifact [25]....
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TL;DR: Noninvasive MDCT angiography is promising but requires further technical improvement to evaluate coronary arteries in pediatric heart transplant patients.
Abstract: Background. The purpose of this study was to assess the feasibility and limitation of multi-detector row computed tomographic (MDCT) imaging for evaluating coronary arteries in pediatric heart transplant patients. Methods. Coronary MDCT angiography was performed in eight pediatric heart transplant recipients. The presence of coronary calcification was evaluated. Luminal changes of the visualized coronary segments on MDCT images were compared with catheter angiographic findings and intravascular ultrasound. Results. Coronary calcification was present in one patient who had severe coronary arteriopathy documented by intravascular ultrasound. In 48 coronary segments visualized on MDCT images, 33, 7, and 4 segments each had normal, luminal irregularities, and moderate stenoses, respectively, which were confirmed by catheter angiography. Twelve coronary segments could not be assessed because of severe motion artifacts. Image quality degradation was more pronounced in patients with higher heart rates. Conclusions. Noninvasive MDCT angiography is promising but requires further technical improvement to evaluate coronary arteries in pediatric heart transplant patients.
24 citations
"Evaluation of coronary allograft va..." refers methods in this paper
...lysis of 25% coronary segments with 4-slice MDCT [22]....
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TL;DR: This data indicates that routine annual coronary angiography has been used as the standard surveillance technique for CAV in most transplant centers and is likely to continue to be used in the future.
Abstract: Background: Cardiac allograft vasculopathy (CAV), a form of accelerated atherosclerosis, is the major cause of late death in heart transplant recipients. Routine annual coronary angiography has been used as the standard surveillance technique for CAV in most transplant centers.
Hypothesis: The aim of this study was to investigate the clinical utility of routine angiographic surveillance in the detection and management of CAV in transplant recipients.
Methods: We reviewed the case notes and angiograms of 230 patients who underwent cardiac transplantation in our unit between January 1986 and January 1996 and survived beyond the first year post transplantation.
Results: Significant complications secondary to angiography arose in 19 patients (8.2%). Cardiac allograft vasculopathy was present on none of angiograms performed 3 weeks post transplantation, but was identified in 9 patients (4%) at the first annual angiogram and an additional 25 patients by the fifth annual angiogram. A target lesion suitable for angioplasty was only identified in two patients, and only limited procedural success was achieved in both cases. Twenty-five patients (11%) died during the study period, and the most common cause of late death was graft failure which occurred in 10 patients. All patients who died from graft failure had significant CAV at autopsy, but the most recent coronary angiogram had been normal in eight of these patients.
Conclusions: These data clearly illustrate the limited clinical utility of routine angiographic surveillance for CAV in heart transplant recipients and prompted us to abandon this method of surveillance in our unit.
23 citations
"Evaluation of coronary allograft va..." refers background in this paper
...However, the clinical utility of annual assessment has been questioned [18]....
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...[21] These risks may increase in the setting of repeated testing as is the standard for transplant patients [18]....
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