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CLINICAL RESEARCH: CARDIAC IMAGING

Prevalence of Different Gadolinium Enhancement Patterns in Patients After Heart Transplantation

Abteilung Innere Medizin III, Medizinische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Germany

Manuscript received November 13, 2007; revised manuscript received March 3, 2008, accepted May 21, 2008.

^_* Reprint requests and correspondence: Dr. Evangelos Giannitsis, Abteilung Innere Medizin III, Medizinische Klinik, Universitätsklinikum Heidelberg, 69120 Heidelberg, Germany (Email: evangelos_giannitsis{at}med.uni-heidelberg.de).

Objectives: Transplant coronary artery disease (TCAD) limits long-term survival after heart transplantation (HTX). We hypothesized that contrast-enhanced magnetic resonance imaging (CE-MRI) detects chronic TCAD-related myocardial infarctions (MIs), even in patients with angiographically classified mild TCAD.

Background: Coronary angiography underestimates the TCAD-degree, subsequently missing occluded small coronary arteries and resulting MI. CE-MRI as a noninvasive imaging technique identifies infarct-typical MI and myocardial fibrosis.

Methods: CE-MRI (gadolinium: 0.2 mmol/kg/bw) was performed in 53 HTX patients on a 1.5-T MRI scanner (Philips, Best, the Netherlands). Infarct-typical CE-MRI areas were classified as: I = 25%, II = 25% to 50%, III = 50% to 75% and IV = 75%. Infarct-atypical forms were divided into diffuse, spotted, intramural, and infero-septal. Coronary angiography results were reviewed qualitatively with the TCAD score (TCAD I = mild evidence; II = 30% to 75%, III = 75% stenosis). Groups were compared with analysis of variance (statistically significant p values 0.05).

Results: Infarct-typical CE-MRI was already present in TCAD I + II, increased significantly between groups (I = 23%, II = 33%, III = 84%, p < 0.05), and involved only single coronary territories in TCAD I but multiple vessels in TCAD II + III. Infarct-atypical CE-MRI was equally distributed across all TCAD stages (I = 50% vs. II = 58% vs. III = 42%, p = NS) without relation to a coronary territory. Patients with only infarct-atypical CE-MRI were associated with significantly better left ventricular function compared with patients with infarct-typical or combined CE-MRI patterns (ejection fraction = 66 ± 6% vs. 45 ± 16% or 60 ± 13%; end-diastolic volume = 139 ± 32 ml vs. 148 ± 27 ml or 164 ± 43 ml; end-systolic volume = 47 ± 15 ml vs. 81 ± 27 ml or 69 ± 38 ml, p 0.05).

Conclusions: CE-MRI allows identification of silent MI in apparently event-free HTX patients and is able to disclose myocardial fibrosis already in patients with absent or mild angiographic TCAD. CE-MRI might be helpful to establish an earlier TCAD diagnosis and to intensify medical treatment. Future studies are necessary to test prognostic implications associated with CE-MRI patterns.

Key Words: atherosclerosis • coronary artery disease • heart transplantation • magnetic resonance imaging • myocardial infarction

Abbreviations and Acronyms   CE-MRI = contrast-enhanced magnetic resonance imaging   EDV = end-diastolic volume   EF = ejection fraction   ESV = end-systolic volume   HTX = heart transplantation   ISHLT = International Society for Heart and Lung Transplantation   IVUS = intravascular ultrasound   LV = left ventricular   MI = myocardial infarction   NT-proBNP = N-terminal part of the pro-B-type natriuretic peptide   TCAD = transplant coronary artery disease   TI = inversion time

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