The Role of Multimodality Cardiac Imaging in the Transplanted Heart
Jerry D. Estep, MD*,
Dipan J. Shah, MD,
Sherif F. Nagueh, MD,
John J. Mahmarian, MD,
Guillermo Torre-Amione, MD, PhD,
William A. Zoghbi, MD
Department of Cardiology, Section of Heart Failure and Heart Transplantation, and Cardiovascular Imaging Institute, Methodist DeBakey Heart and Vascular Center, Houston, Texas
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Figure 1 Different Noninvasive Imaging Techniques Performed at Various Stages of Cardiac Involvement to Detect Acute Cellular Rejection
ACR = acute cellular rejection; CMR = cardiac magnetic resonance; CT = computed tomography; ISHLT = International Society of Heart and Lung Transplantation.
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Figure 2 Noninvasive Detection of Elevated Left Ventricular Filling Pressure in Cardiac Transplant Recipients Using Doppler Echocardiography
(A) Pulsed Doppler recording of the mitral flow velocity and the corresponding annular velocities by tissue Doppler at the time of first right-sided cardiac catheterization. (B) Pulsed Doppler of mitral inflow and the corresponding tissue Doppler velocities at the time of the repeat right-sided cardiac catheterization (4 weeks later). Mean measured pulmonary capillary wedge pressure (PCWP) decreased from 24 to 11 mm Hg. The E/Ea ratio decreased from 15 to 5, predicting a decrease in estimated wedge pressure from 24 to 9 mm Hg (PCWP = 2.6 + 1.46 [E/Ea]). E = peak mitral inflow velocity; Ea = peak mitral annular velocity; MV = mitral valve.
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Figure 3 Global Radial Strain Derived From the Speckle-Tracking Technique
(A) Global radial strain (38%), peak 47%, obtained from the parasternal short axis view in a patient 1 week post-heart transplantation (biopsy grade 2R performed on the same day). (B) Improvement in the global radial strain (58%), peak 68%, 2 weeks later after enhancement in immunosuppression (biopsy grade 1R). ACR = acute cellular rejection; AVC = aortic valve closure.
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Figure 4 CMR Assessment of Left and Right Ventricular Systolic Function Pre- and Post-Treatment of an Episode of Cardiac Rejection
(A) Pre-treatment biventricular dysfunction with a large thrombus in the right ventricular apex (arrow). (B) Two weeks post-treatment there was substantial improvement in biventricular function, and the thrombus appears to have decreased in size with anticoagulation therapy. Full-motion cine images can be viewed online. LVEF = left ventricular ejection fraction; RVEF = right ventricular ejection fraction.
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Figure 5 Hyperenhancement on Cardiac Magnetic Resonance Images in a Patient With ACR
(A) No hyperenhancement 1 week post-transplant. (B) Areas of hyperenhancement in the lateral wall and basal septum (red arrows) during an episode of (grade 2R) ACR. (C) Follow-up demonstrating near-complete resolution of the hyperenhancement in the lateral wall (red arrows) after treatment with intravenous steroids and enhancement of immunosuppression with corresponding EMB revealing resolving (grade 1R) ACR. ACR = acute cellular rejection; EMB = endomyocardial biopsy.
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Figure 6 Different Noninvasive Imaging and Invasive Techniques Performed at Various Stages of Cardiac Involvement to Detect Cardiac Allograft Vasculopathy
CE = contrast-enhanced; CMR = cardiac magnetic resonance; CMV = cytomegalovirus; CT = computed tomography; DE-CMR=delayed enhancement cardiac magnetic resonance; DSE = dobutamine stress echocardiography; HTN = hypertension; IVUS = intravascular ultrasound; MDCT = multidetector computed tomography; MPI = myocardial perfusion imaging; SRI = strain rate imaging; TDI = tissue Doppler imaging.
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Figure 7 MDCT Coronary Angiography Demonstration of Cardiac Allograft Vasculopathy
(A) Total vessel occlusion of left anterior descending (LAD) is illustrated by conventional coronary angiography. (B) Corresponding LAD occlusion by MDCT volume-rendering angiography. (C) Maximum intensity projection; grey arrows indicate site of total vessel occlusion; proximal of occlusion, an excentric noncalcified plaque is depicted in a cross-sectional image (note diffuse hypodense vessel wall changes throughout the LAD course, causing no to minimal luminal irregularities in conventional coronary angiography). LCX = left circumflex; LM = left main coronary artery; MDCT = multidetector computed tomography; RCA = right coronary artery. Adapted from von Ziegler et al. (66) with permission.
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