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Quantitative flow ratio computed from invasive coronary angiography as a predictor for cardiac allograft vasculopathy after cardiac transplant

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Abstract

Cardiac allograft vasculopathy (CAV) is a significant determinant of long-term survival in heart transplant recipients. Standard CAV screening typically utilizes invasive coronary angiography (ICA). Quantitative flow ratio (QFR) is a computational method for functional testing of coronary stenosis, and may add diagnostic value to ICA in assessing CAV. Consecutive subjects who received heart transplantation and underwent two separate routine coronary angiograms between January 2013 and April 2016 were enrolled. Coronary angiograms and IVUS were performed per local protocol at 1, 2, 3 and 5 years post-transplant. QFR was calculated offline. CAV was assessed semi-quantitively based on coronary angiogram results. Twenty-two patients were enrolled. Mean time from transplant to first included ICA was 2.1 years. QFR in at least 1 coronary vessel was interpretable in 19/22 (86%) of initial ICA (QFR1). QFR1 correlated well with the CAV score derived from the second ICA (CAV2) with a clustering of CAV at lower QFR values. In a receiver-operating characteristic (ROC) analysis, an optimal QFR threshold of 0.88 yielded 0.94 sensitivity and 0.67 specificity (AUC of 0.79) for at least non-obstructive subsequent CAV. Initial angiographically and intravascular ultrasound derived CAV severity poorly predicted subsequent CAV severity. QFR derived from invasive coronary angiography predicts subsequent development of CAV more accurately than angiography and intravascular ultrasound. This novel method of coronary flow assessment in recipients of heart transplantation may be useful to diagnose and predict subsequent CAV development.

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Abbreviations

CAV:

Cardiac allograft vasculopathy

ICA:

Invasive coronary angiography

IVUS:

Intravascular ultrasound

FFR:

Fractional flow reserve

LAD:

Left anterior descending coronary artery

LCX:

Left circumflex coronary artery

PCI:

Percutaneous coronary intervention

QCA:

Quantitative coronary angiography

QFR:

Quantitative flow ratio

RCA:

Right coronary artery

SCD:

Sudden cardiac death

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Acknowledgements

The authors are appreciative of the transplant recipients, their families, and the entire heart transplant team at MedStar Washington Hospital Center.

Funding

This study was investigator initiated and not supported with grant or industry funding.

Author information

Authors and Affiliations

  1. Department of Cardiology, Jefferson Einstein Hospital, Philadelphia, PA, USA

    Harsh Shah

  2. Department of Medicine, MedStar Georgetown University Hospital, Washington, DC, USA

    Injoon Lee

  3. Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA

    Sriram Rao, William Suddath, Maria Rodrigo & Benjamin B. Kenigsberg

  4. Department of Cardiology, Creighton University School of Medicine, Omaha, NE, USA

    Selma Mohammed

  5. Department of Cardiac Surgery, Piedmont Heart Institute, Atlanta, GA, USA

    Ezequiel Molina

  6. MedStar Cardiovascular Research Network, MedStar Washington Hospital Center, Washington, DC, USA

    Hector M. García-Garcia

  7. Department of Critical Care, MedStar Washington Hospital Center, 110 Irving St., NW, Rm A121, Washington, DC, 20010, USA

    Benjamin B. Kenigsberg

Authors
  1. Harsh Shah
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  2. Injoon Lee
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Contributions

HS: Investigation, writing—original draft, visualization. IL: Validation, investigation, writing—original draft, visualization. SR: Validation, formal analysis, writing—review and editing. WS: Resources, writing—review and editing. MR: Resources, writing—review and editing. SM: Methodology, formal analysis, writing—review and editing, supervision. EM: Resources, writing—review and editing. HMG-G: Methodology, resources, writing—review and editing, supervision. BBK: Conceptualization, methodology, validation, investigation, data curation, writing—original draft, visualization, supervision, project administration. All authors have contributed to the manuscript and have approved it for the submission.

Corresponding author

Correspondence to Benjamin B. Kenigsberg.

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Competing interests

Investigator HGG reports receiving institutional grants from Biotronik, Boston Scientific, Medtronic, Abbott Vascular, Neovasc, Shockwave, Phillips and Corflow. Investigator EM receives funding from Abbott. There are no other conflicts of interest to disclose.

Ethical approval

The study was approved by the institutional review board of the Medstar Washington Hospital Center with a waiver of consent. In addition, there was strict adherence to guidelines for rigorous reporting of results.

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Shah, H., Lee, I., Rao, S. et al. Quantitative flow ratio computed from invasive coronary angiography as a predictor for cardiac allograft vasculopathy after cardiac transplant. Int J Cardiovasc Imaging 40, 451–458 (2024). https://doi.org/10.1007/s10554-023-03012-8

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  • DOI: https://doi.org/10.1007/s10554-023-03012-8

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