Cardiac Magnetic Resonance Imaging Noninvasively Detects Rejection in Pediatric Heart Transplant Recipients

Soslow, Jonathan H.; Godown, Justin; Bearl, David W.; Crum, Kimberly; Slaughter, James C.; George‐Durrett, Kristen; Chan, Kak‐Chen; Chrisant, Maryanne; Dodd, Debra A.; Hernandez, Lazaro

doi:10.1161/circimaging.121.013456

Cited by 6 publications

(9 citation statements)

References 4 publications

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“…A recent meta-analysis done by Han et al suggested that T2 has the highest diagnostic performance in terms of CMR mapping data as suggested by several other studies in HT studying the role of CMR in rejection surveillance. 11,12,[29][30][31][32][33] Interestingly, Dolan et al noted that not only was T2 elevated in patients with acute rejection, but also in patients with a history of acute rejection, which is similar to our finding of elevated T2 in patients with historical moderate/severe rejection. 11 The mechanism driving elevated global and peak T2 in these populations is likely multifactorial, such as inflammation from ongoing rejection or vascular inflammation related to CAV that is undetectable by EMB pathology and subclinical heart failure leading to disruption in myocardial fluid balance.…”

Section: Relationship Between Emb and Cmr Findingssupporting

confidence: 90%

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Cardiac magnetic resonance imaging in detection of progressive graft dysfunction in pediatric heart transplantation

Watanabe,

Arva,

Robinson

et al. 2023

Pediatric Transplantation

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BackgroundChronic graft failure (CGF) in pediatric heart transplant (PHT) is multifactorial and may present with findings of fibrosis and microvessel disease (MVD) on endomyocardial biopsy (EMB). There is no optimal CGF surveillance method. We evaluated associations between cardiac magnetic resonance imaging (CMR) and historical/EMB correlates of CGF to assess CMR's utility as a surveillance method.MethodsRetrospective analysis of PHT undergoing comprehensive CMR between September 2015 and January 2022 was performed. EMB within 6 months was graded for fibrosis (scale 0–5) and MVD (number of capillaries with stenotic wall thickening per field of view). Correlation analysis and logistic regression were performed.ResultsForty‐seven PHT with median age at CMR of 15.7 years (11.6, 19.3) and time from transplant of 6.4 years (4.1, 11.0) were studied. Cardiac allograft vasculopathy (CAV) was present in 11/44 (22.0%) and historical rejection in 14/41 (34.2%). CAV was associated with higher global T2 (49.0 vs. 47.0 ms; p = 0.038) and peak T2 (57.0 vs. 53.0 ms; p = 0.013) on CMR. Historical rejection was associated with higher global T2 (49.0 vs. 47.0 ms; p = 0.007) and peak T2 (57.0 vs. 53.0 ms; p = 0.03) as well as global extracellular volume (31.0 vs. 26.3%; p = 0.03). Higher fibrosis score on EMB correlated with smaller indexed left ventricular mass (rho = −0.34; p = 0.019) and greater degree of MVD with lower indexed left ventricular end‐diastolic volume (rho = −0.35; p = 0.017).ConclusionAdverse ventricular remodeling and abnormal myocardial characteristics on CMR are present in PHT with CAV, historical rejection, as well as greater fibrosis and MVD on EMB. CMR has the potential use for screening of CGF.

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Section: Relationship Between Emb and Cmr Findingssupporting

confidence: 90%

“…A recent meta‐analysis done by Han et al. suggested that T2 has the highest diagnostic performance in terms of CMR mapping data as suggested by several other studies in HT studying the role of CMR in rejection surveillance 11,12,29–33 . Interestingly, Dolan et al.…”

Section: Discussionmentioning

confidence: 91%

Cardiac magnetic resonance imaging in detection of progressive graft dysfunction in pediatric heart transplantation

Watanabe,

Arva,

Robinson

et al. 2023

Pediatric Transplantation

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“…Additionally, novel noninvasive approaches to graft monitoring, including donor-derived cell-free DNA and cardiac magnetic resonance, may further impact surveillance strategies and impact overall graft monitoring cost. [15][16][17] Our study has a number of limitations. There is a clear selection bias arising from the recruitment methods used.…”

Section: Discussionmentioning

confidence: 97%

“…Therefore, it may be feasible to safely reduce the number of surveillance endomyocardial biopsies. Additionally, novel non‐invasive approaches to graft monitoring, including donor‐derived cell‐free DNA and cardiac magnetic resonance, may further impact surveillance strategies and impact overall graft monitoring cost 15–17 …”

Section: Discussionmentioning

confidence: 99%

Out‐of‐pocket expenses associated with pediatric heart transplantation

Kaslow

Jaworski

Crawford

et al. 2023

Pediatric Transplantation

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Introduction Heart transplantation in children is associated with high resource utilization. However, the financial burden on families and the association with patient and demographic factors remains unclear. This study aims to examine out‐of‐pocket expenses associated with pediatric heart transplantation. Methods An anonymous REDCap survey was distributed to caregivers of children who have undergone heart transplantation using social media, national organizations, and during clinic encounters from May through August 2022. Results There were a total of 146 respondents. The median monthly out‐of‐pocket expense was $250 (IQR $75–$500) and 20 respondents (13.7%) reported monthly expenses of >$1000. Families with commercial insurance reported significantly higher out‐of‐pocket expenses compared to those with government‐sponsored insurance (median $350 vs. $100, p < .001). Families with government‐sponsored insurance were most happy with their insurance coverage, followed by commercial insurance and then coverage through the Affordable Care Act (p < .001 for all pairwise comparisons). There was no statistically significant difference in overall transplant‐related out‐of‐pocket expenses based on total household income (p = .222). Monthly out‐of‐pocket expense was not associated with the number of medications, type of immunosuppressants, or post‐transplant complications including rejection, PTLD, or CAV (p = NS for all). Cardiac catheterizations and unplanned admissions were reported as the events that incurred the highest out‐of‐pocket expense. Conclusion Families of children who have undergone heart transplantation can incur significant out‐of‐pocket expenses and strategies to mitigate this financial burden should be investigated.

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“…The adult literature suggests a role for routine CMR with LGE assessment in the clinical surveillance of heart transplant recipients [ 8 – 10 ]. In smaller studies of CMR in PHTR to date the reported prevalence of LGE varies significantly from 0 to 67% [ 12 – 16 ] in cohorts with variable inclusion criteria, and the prognostic value of LGE for subsequent clinical outcomes has not been evaluated. In this study, we aimed to describe the prevalence, pattern, and extent of myocardial LGE in a cohort of PHTR at a pediatric hospital.…”

Section: Introductionmentioning

confidence: 99%

Late-gadolinium enhancement is common in older pediatric heart transplant recipients and is associated with lower ejection fraction

Lawson,

Watanabe,

Griffin

et al. 2023

Journal of Cardiovascular Magnetic Resonance

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Background Chronic graft failure and cumulative rejection history in pediatric heart transplant recipients (PHTR) are associated with myocardial fibrosis on endomyocardial biopsy (EMB). Cardiovascular magnetic resonance imaging (CMR) is a validated, non-invasive method to detect myocardial fibrosis via the presence of late gadolinium enhancement (LGE). In adult heart transplant recipients, LGE is associated with increased risk of future adverse clinical events including hospitalization and death. We describe the prevalence, pattern, and extent of LGE on CMR in a cohort of PHTR and its associations with recipient and graft characteristics. Methods This was a retrospective study of consecutive PHTR who underwent CMR over a 6-year period at a single center. Two independent reviewers assessed the presence and distribution of left ventricular (LV) LGE using the American Heart Association (AHA) 17-segment model. LGE quantification was performed on studies with visible fibrosis (LGE+). Patient demographics, clinical history, and CMR-derived volumetry and ejection fractions were obtained. Results Eighty-one CMR studies were performed on 59 unique PHTR. Mean age at CMR was 14.8 ± 6.2 years; mean time since transplant was 7.3 ± 5.0 years. The CMR indication was routine surveillance (without a clinical concern based on laboratory parameters, echocardiography, or cardiac catheterization) in 63% (51/81) of studies. LGE was present in 36% (29/81) of PHTR. In these LGE + studies, patterns included inferoseptal in 76% of LGE + studies (22/29), lateral wall in 41% (12/29), and diffuse, involving > 4 AHA segments, in 21% (6/29). The mean LV LGE burden as a percentage of myocardial mass was 18.0 ± 9.0%. When reviewing only the initial CMR per PHTR (n = 59), LGE + patients were older (16.7 ± 2.9 vs. 12.8 ± 4.6 years, p = 0.001), with greater time since transplant (8.3 ± 5.4 vs. 5.7 ± 3.9 years, p = 0.041). These patients demonstrated higher LV end-systolic volume index (LVESVI) (34.7 ± 11.7 vs. 28.7 ± 6.1 ml/m2, p = 0.011) and decreased LV ejection fraction (LVEF) (56.2 ± 8.1 vs. 60.6 ± 5.3%, p = 0.015). There were no significant differences in history of moderate/severe rejection (p = 0.196) or cardiac allograft vasculopathy (CAV) (p = 0.709). Conclusions LV LGE was present in approximately one third of PHTR, more commonly in older patients with longer time since transplantation. Grafts with LGE have lower LVEF. CMR-derived LGE may aid in surveillance of chronic graft failure in PHTR.

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Cardiac Magnetic Resonance Imaging Noninvasively Detects Rejection in Pediatric Heart Transplant Recipients

Cited by 6 publications

References 4 publications

Cardiac magnetic resonance imaging in detection of progressive graft dysfunction in pediatric heart transplantation

Cardiac magnetic resonance imaging in detection of progressive graft dysfunction in pediatric heart transplantation

Out‐of‐pocket expenses associated with pediatric heart transplantation

Late-gadolinium enhancement is common in older pediatric heart transplant recipients and is associated with lower ejection fraction

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