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

Kevin J. Clerkin, Veli K. Topkara, Maryjane A. Farr, Rashmi Jain, Paolo C. Colombo, Susan Restaino, Gabriel Sayer, Michelle Castillo, Elaine Y. Lam, Margarita Chernovolenko, Melana Yuzefpolskaya, Ersilia DeFilippis, Farhana Latif, Emmanuel Zorn, Koji Takeda, Lynne L. Johnson, Nir Uriel, Andrew J. Einstein

Research output: Contribution to journalArticlepeer-review

7 Scopus citations


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 affects 50% of heart transplant recipients within 10 years of heart transplant. Objectives: This analysis examined the outcomes of heart transplant recipients with reduced myocardial blood flow reserve (MBFR) and microvascular CAV detected by 13N-ammonia positron emission tomography (PET) myocardial perfusion imaging. Methods: A total of 181 heart transplant recipients who underwent PET to assess for CAV were included with a median follow-up of 4.7 years. Patients were classified into 2 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: In total, 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; P < 0.0001), 12-fold increase in cardiovascular death (HR: 12.0; 95% CI: 2.64-54.12; P = 0.001), and 10-fold increase in cardiovascular hospitalization (HR: 10.1; 95% CI: 3.43-29.9; P < 0.0001). The 5-year mean survival was 302 days less than those with an MBFR >2.0 (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.

Original languageEnglish (US)
Pages (from-to)1617-1628
Number of pages12
JournalJournal of the American College of Cardiology
Issue number17
StatePublished - Oct 25 2022
Externally publishedYes


  • cardiac allograft vasculopathy
  • heart transplant
  • microvascular dysfunction
  • positron emission tomography
  • prognosis

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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