Noninvasive diagnosis coronary computed tomographic angiography lesions of coronary arteries of the transplanted heart

Background. Coronary artery disease (CAD) is one of the leading causes of graft loss after heart transplantation (HT). Owing to cardiac denervation, myocardial ischemia in transplanted hearts is typically clinically silent, necessitating regular screening of recipients to detect transplant vasculopathy. Routine annual invasive coronary angiography (iCAG), however, is associated with potentially life-threatening complications, prompting the search for safe and equally effective non-invasive diagnostic alternatives. Multislice computed tomography coronary angiography (MSCT-CAG) has been widely and successfully used for many years in CAD diagnosis, with a high class and level of evidence, and has long been an alternative to iCAG. This underscores the relevance of evaluating its applicability in heart transplant recipients.

Objective: to assess the diagnostic effectiveness of MSCT-CAG in detecting cardiac allograft vasculopathy in comparison with iCAG.

Materials and methods. The study included 46 heart transplant recipients (36 men, 78%) aged 29–68 years (mean age 51.1 ± 10.9 years) who underwent HT between 2012 and 2023. The interval from transplantation to CAG ranged from 201 to 4,285 days (mean 1,097 days). All patients underwent scheduled iCAG and MSCT-CAG. Coronary arteries were evaluated using a 16-segment model. Segments that could not be reliably assessed on MSCT-CAG images were excluded from the analysis.

Results. Heart rate during MSCT-CAG ranged from 65 to 105 beats per minute (median 90 bpm) and was not adjusted with medication prior to scanning. Invasive CAG allowed assessment of 690 coronary segments, while 683 segments were of diagnostic quality on MSCT-CAG. According to iCAG, coronary lesions were identified in 25 segments. MSCT-CAG detected lesions in 15 segments, yielded false-positive findings in 14 segments, and failed to identify stenoses detected by invasive CAG in 10 segments. X-ray dose was significantly higher during MSCT-CAG (22.6 mSv) compared with iCAG (10 mSv; p = 0.001). MSCT-CAG also required a larger volume of contrast medium (90 mL vs. 60 mL; p = 0.001). Serum creatinine levels before and after MSCT-CAG were 91.35 ± 18.09 and 95.17 ± 18.53 μmol/L, respectively, while glomerular filtration rate (GFR) values were 86.28 ± 17.79 and 82.96 ± 17.72 mL/min/1.73 m². Despite the higher contrast load and compromised renal function due to the nephrotoxicity of immunosuppressive therapy, no cases of contrast-induced nephropathy were observed following MSCT-CAG. Comparative analysis demonstrated that MSCT-CAG had a sensitivity of 60%, specificity of 97%, positive predictive value of 52%, and negative predictive value of 98% relative to iCAG.

Conclusion. In the diagnosis of cardiac allograft vasculopathy, MSCT-CAG can be used to rule out coronary artery stenosis, demonstrating high specificity (97%) and negative predictive value (98%). The use of MSCT-CAG for the detection of stenosis/restenosis of the coronary vasculature in transplanted hearts requires further study.

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