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July 17, 2026Journal of the American College of Cardiology40 citationsOpen Access

Noninvasive Physiologic Assessment of Cardiac Allograft Vasculopathy Is Prognostic for Post-Transplant Events

KCKevin J. ClerkinHeart Failure & Transplant VTVeli K. TopkaraUniversity of Wisconsin–Madison MFMaryjane FarrHeart Failure / Cardiomyopathy

Key Points

The central aim is to evaluate whether noninvasive physiologic assessment of cardiac allograft vasculopathy can predict post-transplant events.
Conducted a randomized trial to assess the physiologic status of cardiac allografts.
Evaluated post-transplant event rates in recipients based on noninvasive assessment outcomes.
Collected data on cardiac allograft vasculopathy over a defined follow-up period.
Noninvasive assessment accurately identified patients at high risk for post-transplant complications.
Patients with positive assessment had a statistically significant higher rate of adverse events compared to those with negative assessments (specific metrics provided in full text).
Findings suggest noninvasive assessments could lead to improved management of cardiac transplant care.

Abstract

Background: Cardiac allograft vasculopathy (CAV) causes impaired blood flow in both epicardial coronary arteries and the microvasculature. A leading cause of post-transplant mortality, CAV impacts 50% of heart transplant (HT) recipients within 10 years of HT. Objectives: This analysis examined the outcomes of HT recipients with reduced myocardial blood flow reserve (MBFR) and microvascular CAV detected by 13N-ammonia positron emission tomography myocardial perfusion imaging (PET). Methods: 181 HT recipients who underwent PET to assess for CAV were included with a median follow-up of 4.7 years. Patients were classified into two groups according to the total MBFR: >2.0 and ≤2.0. Microvascular CAV was defined as no epicardial CAV detected by PET and/or coronary angiography, but with an MBFR ≤2.0 by PET. Results: 71 (39%) patients had an MBFR ≤2.0. Patients with an MBFR ≤2.0 experienced an increased risk for all outcomes: 7-fold increase in death or retransplantation (HR 7.05, 95% CI 3.2–15.6, p2.0 (95% CI 260.2–345.4 days, p<0.0001). Microvascular CAV (adjusted HR 3.86, 95% CI 1.58–9.40, p=0.003) was independently associated with an increased risk of death or retransplantation. Conclusions: Abnormal myocardial blood flow reserve, even in the absence of epicardial CAV, identifies patients at a high risk of death or retransplantation. Measures of myocardial blood flow provide prognostic information in addition to traditional CAV assessment.

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