wikidoc - User contributions [en]

Cardiac allograft vasculopathy history and symptoms

2014-09-28T18:50:37Z

Raviteja Reddy Guddeti:

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Patients with cardiac allograft vasculopathy (CAV) do not present with typical angina symptoms due to cardiac denervation at the time of heart transplantation. CAV is responsible for approximately 40% of deaths in heart transplant recipients. Survival in these patients has improved significantly over the decades, owing primarily to improved diagnostic techniques, and optimal immunosuppression and risk factor modification. The 2013 adult heart transplant registry noted that 5-year survival in both pediatric and adult heart transplant recipients is 69%.

==History and Symptoms==
CAV may manifest as:
# [[Graft]] failure
# [[Arrhythmia]]s
# Silent [[myocardial infarction]]: Due to denervation at the time of surgery patients with CAV rarely present with typical [[angina]] symptoms, especially in the initial years of [[transplantation]].<ref name="pmid16102462">{{cite journal| author=Di Cori A, Petronio AS, Gemignani C, Zucchelli G, Di Bello V, Mariani M| title=Symptomatic acute myocardial infarction in a cardiac transplant recipient successfully treated with primary coronary angioplasty: evidence of prognostic importance of chest pain after cardiac transplantation. | journal=J Heart Lung Transplant | year= 2005 | volume= 24 | issue= 8 | pages= 1146-9 | pmid=16102462 | doi=10.1016/j.healun.2004.07.003 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16102462 }} </ref> However, studies have demonstrated that re-innervation does occur late after [[heart transplantation]].<ref name="pmid15366426">{{cite journal| author=Gallego-Page JC, Segovia J, Alonso-Pulpón L, Alonso-Rodríguez M, Salas C, Ortíz-Berrocal J| title=Re-innervation after heart transplantation: a multidisciplinary study. | journal=J Heart Lung Transplant | year= 2004 | volume= 23 | issue= 6 | pages= 674-82 | pmid=15366426 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15366426 }} </ref>
# [[Sudden death]]

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy history and symptoms

2014-09-28T18:23:28Z

Raviteja Reddy Guddeti: /* History and Symptoms */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==

==History and Symptoms==
CAV may manifest as:
# [[Graft]] failure
# [[Arrhythmia]]s
# Silent [[myocardial infarction]]: Due to denervation at the time of surgery patients with CAV rarely present with typical [[angina]] symptoms, especially in the initial years of [[transplantation]].<ref name="pmid16102462">{{cite journal| author=Di Cori A, Petronio AS, Gemignani C, Zucchelli G, Di Bello V, Mariani M| title=Symptomatic acute myocardial infarction in a cardiac transplant recipient successfully treated with primary coronary angioplasty: evidence of prognostic importance of chest pain after cardiac transplantation. | journal=J Heart Lung Transplant | year= 2005 | volume= 24 | issue= 8 | pages= 1146-9 | pmid=16102462 | doi=10.1016/j.healun.2004.07.003 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16102462 }} </ref> However, studies have demonstrated that re-innervation does occur late after [[heart transplantation]].<ref name="pmid15366426">{{cite journal| author=Gallego-Page JC, Segovia J, Alonso-Pulpón L, Alonso-Rodríguez M, Salas C, Ortíz-Berrocal J| title=Re-innervation after heart transplantation: a multidisciplinary study. | journal=J Heart Lung Transplant | year= 2004 | volume= 23 | issue= 6 | pages= 674-82 | pmid=15366426 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15366426 }} </ref>
# [[Sudden death]]

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy history and symptoms

2014-09-28T18:21:26Z

Raviteja Reddy Guddeti: /* History and Symptoms */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==

==History and Symptoms==
CAV may manifest as:
# [[Graft failure]]
# [[Arrhythmia]]s
# Silent [[myocardial infarction]]: Due to denervation at the time of surgery patients with CAV rarely present with typical [[angina]] symptoms, especially in the initial years of [[transplantation]].<ref name="pmid16102462">{{cite journal| author=Di Cori A, Petronio AS, Gemignani C, Zucchelli G, Di Bello V, Mariani M| title=Symptomatic acute myocardial infarction in a cardiac transplant recipient successfully treated with primary coronary angioplasty: evidence of prognostic importance of chest pain after cardiac transplantation. | journal=J Heart Lung Transplant | year= 2005 | volume= 24 | issue= 8 | pages= 1146-9 | pmid=16102462 | doi=10.1016/j.healun.2004.07.003 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16102462 }} </ref> However, studies have demonstrated that re-innervation does occur late after [[heart transplantation]].<ref name="pmid15366426">{{cite journal| author=Gallego-Page JC, Segovia J, Alonso-Pulpón L, Alonso-Rodríguez M, Salas C, Ortíz-Berrocal J| title=Re-innervation after heart transplantation: a multidisciplinary study. | journal=J Heart Lung Transplant | year= 2004 | volume= 23 | issue= 6 | pages= 674-82 | pmid=15366426 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15366426 }} </ref>
# [[Sudden death]]

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy history and symptoms

2014-09-28T18:20:24Z

Raviteja Reddy Guddeti: Created page with "__NOTOC__ {{Cardiac allograft vasculopathy}} {{CMG}}; {{AE}} {{AN}}; {{RT}} ==Overview== ==History and Symptoms== CAV may manifest as: 1. Graft failure 2. Arrhythmia..."

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==

==History and Symptoms==
CAV may manifest as:
1. [[Graft failure]]
2. [[Arrhythmia]]s
3. Silent [[myocardial infarction]]: Due to denervation at the time of surgery patients with CAV rarely present with typical [[angina]] symptoms, especially in the initial years of [[transplantation]].<ref name="pmid16102462">{{cite journal| author=Di Cori A, Petronio AS, Gemignani C, Zucchelli G, Di Bello V, Mariani M| title=Symptomatic acute myocardial infarction in a cardiac transplant recipient successfully treated with primary coronary angioplasty: evidence of prognostic importance of chest pain after cardiac transplantation. | journal=J Heart Lung Transplant | year= 2005 | volume= 24 | issue= 8 | pages= 1146-9 | pmid=16102462 | doi=10.1016/j.healun.2004.07.003 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16102462 }} </ref> However, studies have demonstrated that re-innervation does occur late after [[heart transplantation]].<ref name="pmid15366426">{{cite journal| author=Gallego-Page JC, Segovia J, Alonso-Pulpón L, Alonso-Rodríguez M, Salas C, Ortíz-Berrocal J| title=Re-innervation after heart transplantation: a multidisciplinary study. | journal=J Heart Lung Transplant | year= 2004 | volume= 23 | issue= 6 | pages= 674-82 | pmid=15366426 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15366426 }} </ref>

4. [[Sudden death]]

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy other imaging findings

2014-09-28T18:04:07Z

Raviteja Reddy Guddeti: /* Dobutamine Stress Echocardiogram */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Non-invasive testing by stress electrocardiography is of limited use in the diagnosis of cardiac allograft vasculopathy (CAV) due to high frequency of baseline electrocardiographic abnormalities and the reduced exercise tolerance in heart transplant recipients. Therefore adjunctive imaging in the form of stress echocardiogram and radionuclide imaging to improve sensitivity and specificity has been used for this purpose.

==Other Imaging Findings==
===Dobutamine Stress Echocardiogram===
Akosah et al first reported the use of dobutamine stress echocardiogram (DSE) in the diagnosis of CAV.<ref name="pmid7865509">{{cite journal| author=Akosah KO, Mohanty PK, Funai JT, Jesse RL, Minisi AJ, Crandall CW et al.| title=Noninvasive detection of transplant coronary artery disease by dobutamine stress echocardiography. | journal=J Heart Lung Transplant | year= 1994 | volume= 13 | issue= 6 | pages= 1024-38 | pmid=7865509 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7865509 }} </ref> The study demonstrated the sensitivity, specificity, negative predictive value and positive predictive value of DSE to be 95%, 55%, 69% and 92% respectively. Subsequently several studies compared the efficacy of DSE in combination with coronary angiography and with or without intravascular ultrasound for detecting the presence and severity of CAV.<ref name="pmid9563602">{{cite journal| author=Derumeaux G, Redonnet M, Soyer R, Cribier A, Letac B| title=Assessment of the progression of cardiac allograft vasculopathy by dobutamine stress echocardiography. | journal=J Heart Lung Transplant | year= 1998 | volume= 17 | issue= 3 | pages= 259-67 | pmid=9563602 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9563602 }} </ref><ref name="pmid9626841">{{cite journal| author=Akosah KO, McDaniel S, Hanrahan JS, Mohanty PK| title=Dobutamine stress echocardiography early after heart transplantation predicts development of allograft coronary artery disease and outcome. | journal=J Am Coll Cardiol | year= 1998 | volume= 31 | issue= 7 | pages= 1607-14 | pmid=9626841 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9626841 }} </ref><ref name="pmid10430765">{{cite journal| author=Spes CH, Klauss V, Mudra H, Schnaack SD, Tammen AR, Rieber J et al.| title=Diagnostic and prognostic value of serial dobutamine stress echocardiography for noninvasive assessment of cardiac allograft vasculopathy: a comparison with coronary angiography and intravascular ultrasound. | journal=Circulation | year= 1999 | volume= 100 | issue= 5 | pages= 509-15 | pmid=10430765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10430765 }} </ref><ref name="pmid8712138">{{cite journal| author=Spes CH, Mudra H, Schnaack SD, Klauss V, Reichle FM, Uberfuhr P et al.| title=Dobutamine stress echocardiography for noninvasive diagnosis of cardiac allograft vasculopathy: a comparison with angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 1996 | volume= 78 | issue= 2 | pages= 168-74 | pmid=8712138 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8712138 }} </ref><ref name="pmid7759721">{{cite journal| author=Derumeaux G, Redonnet M, Mouton-Schleifer D, Bessou JP, Cribier A, Saoudi N et al.| title=Dobutamine stress echocardiography in orthotopic heart transplant recipients. VACOMED Research Group. | journal=J Am Coll Cardiol | year= 1995 | volume= 25 | issue= 7 | pages= 1665-72 | pmid=7759721 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7759721 }} </ref> Spes et al, in a study to evaluate the value of DSE for non-invasive diagnosis of CAV compared with coronary angiography and IVUS, demonstrated that regional myocardial dysfunction as assessed by DSE correlated well with IVUS-derived evidence of moderate to severe intimal hyperplasia. The study concluded that DSE could be used as a feasible alternative noninvasive diagnostic method to diagnose CAV and may indeed reduce the need for frequent invasive screening by coronary angiography.<ref name="pmid8712138">{{cite journal| author=Spes CH, Mudra H, Schnaack SD, Klauss V, Reichle FM, Uberfuhr P et al.| title=Dobutamine stress echocardiography for noninvasive diagnosis of cardiac allograft vasculopathy: a comparison with angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 1996 | volume= 78 | issue= 2 | pages= 168-74 | pmid=8712138 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8712138 }} </ref> In a similar study by the same group to determine the prognostic value of DSE in CAV compared with coronary angiography and IVUS it was found that the prognostic value of DSE was comparable to that of angiography and IVUS.<ref name="pmid10430765">{{cite journal| author=Spes CH, Klauss V, Mudra H, Schnaack SD, Tammen AR, Rieber J et al.| title=Diagnostic and prognostic value of serial dobutamine stress echocardiography for noninvasive assessment of cardiac allograft vasculopathy: a comparison with coronary angiography and intravascular ultrasound. | journal=Circulation | year= 1999 | volume= 100 | issue= 5 | pages= 509-15 | pmid=10430765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10430765 }} </ref> Across several studies, the sensitivity, specificity, positive predictive value and negative predictive value of DSE for the diagnosis of CAV in comparison to angiography has been reported to be ranging from 65% to 95%, 55% to 95%, 69% to 92%, and 71% to 92%, respectively.<ref name="pmid23680373">{{cite journal| author=Pollack A, Nazif T, Mancini D, Weisz G| title=Detection and imaging of cardiac allograft vasculopathy. | journal=JACC Cardiovasc Imaging | year= 2013 | volume= 6 | issue= 5 | pages= 613-23 | pmid=23680373 | doi=10.1016/j.jcmg.2013.03.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23680373 }} </ref> However, with the addition of IVUS to coronary angiography and DSE the sensitivity and negative predictive value of DSE were reported to be low compared with IVUS.<ref name="pmid23680373">{{cite journal| author=Pollack A, Nazif T, Mancini D, Weisz G| title=Detection and imaging of cardiac allograft vasculopathy. | journal=JACC Cardiovasc Imaging | year= 2013 | volume= 6 | issue= 5 | pages= 613-23 | pmid=23680373 | doi=10.1016/j.jcmg.2013.03.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23680373 }} </ref>

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy other imaging findings

2014-09-28T17:57:42Z

Raviteja Reddy Guddeti: /* Dobutamine Stress Echocardiogram */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Non-invasive testing by stress electrocardiography is of limited use in the diagnosis of cardiac allograft vasculopathy (CAV) due to high frequency of baseline electrocardiographic abnormalities and the reduced exercise tolerance in heart transplant recipients. Therefore adjunctive imaging in the form of stress echocardiogram and radionuclide imaging to improve sensitivity and specificity has been used for this purpose.

==Other Imaging Findings==
===Dobutamine Stress Echocardiogram===
Akosah et al first reported the use of dobutamine stress echocardiogram (DSE) in the diagnosis of CAV.<ref name="pmid7865509">{{cite journal| author=Akosah KO, Mohanty PK, Funai JT, Jesse RL, Minisi AJ, Crandall CW et al.| title=Noninvasive detection of transplant coronary artery disease by dobutamine stress echocardiography. | journal=J Heart Lung Transplant | year= 1994 | volume= 13 | issue= 6 | pages= 1024-38 | pmid=7865509 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7865509 }} </ref> The study demonstrated the sensitivity, specificity, negative predictive value and positive predictive value of DSE to be 95%, 55%, 69% and 92% respectively. Subsequently several studies compared the efficacy of DSE in combination with coronary angiography and with or without intravascular ultrasound for detecting the presence and severity of CAV.<ref name="pmid9563602">{{cite journal| author=Derumeaux G, Redonnet M, Soyer R, Cribier A, Letac B| title=Assessment of the progression of cardiac allograft vasculopathy by dobutamine stress echocardiography. | journal=J Heart Lung Transplant | year= 1998 | volume= 17 | issue= 3 | pages= 259-67 | pmid=9563602 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9563602 }} </ref><ref name="pmid9626841">{{cite journal| author=Akosah KO, McDaniel S, Hanrahan JS, Mohanty PK| title=Dobutamine stress echocardiography early after heart transplantation predicts development of allograft coronary artery disease and outcome. | journal=J Am Coll Cardiol | year= 1998 | volume= 31 | issue= 7 | pages= 1607-14 | pmid=9626841 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9626841 }} </ref><ref name="pmid10430765">{{cite journal| author=Spes CH, Klauss V, Mudra H, Schnaack SD, Tammen AR, Rieber J et al.| title=Diagnostic and prognostic value of serial dobutamine stress echocardiography for noninvasive assessment of cardiac allograft vasculopathy: a comparison with coronary angiography and intravascular ultrasound. | journal=Circulation | year= 1999 | volume= 100 | issue= 5 | pages= 509-15 | pmid=10430765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10430765 }} </ref><ref name="pmid8712138">{{cite journal| author=Spes CH, Mudra H, Schnaack SD, Klauss V, Reichle FM, Uberfuhr P et al.| title=Dobutamine stress echocardiography for noninvasive diagnosis of cardiac allograft vasculopathy: a comparison with angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 1996 | volume= 78 | issue= 2 | pages= 168-74 | pmid=8712138 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8712138 }} </ref><ref name="pmid7759721">{{cite journal| author=Derumeaux G, Redonnet M, Mouton-Schleifer D, Bessou JP, Cribier A, Saoudi N et al.| title=Dobutamine stress echocardiography in orthotopic heart transplant recipients. VACOMED Research Group. | journal=J Am Coll Cardiol | year= 1995 | volume= 25 | issue= 7 | pages= 1665-72 | pmid=7759721 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7759721 }} </ref> Spes et al, in a study to evaluate the value of DSE for non-invasive diagnosis of CAV compared with coronary angiography and IVUS, demonstrated that regional myocardial dysfunction as assessed by DSE correlated well with IVUS-derived evidence of moderate to severe intimal hyperplasia. The study concluded that DSE could be used as a feasible alternative noninvasive diagnostic method to diagnose CAV and may indeed reduce the need for frequent invasive screening by coronary angiography.<ref name="pmid8712138">{{cite journal| author=Spes CH, Mudra H, Schnaack SD, Klauss V, Reichle FM, Uberfuhr P et al.| title=Dobutamine stress echocardiography for noninvasive diagnosis of cardiac allograft vasculopathy: a comparison with angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 1996 | volume= 78 | issue= 2 | pages= 168-74 | pmid=8712138 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8712138 }} </ref> In a similar study by the same group to determine the prognostic value of DSE in CAV compared with coronary angiography and IVUS it was found that the prognostic value of DSE was comparable to that of angiography and IVUS.<ref name="pmid10430765">{{cite journal| author=Spes CH, Klauss V, Mudra H, Schnaack SD, Tammen AR, Rieber J et al.| title=Diagnostic and prognostic value of serial dobutamine stress echocardiography for noninvasive assessment of cardiac allograft vasculopathy: a comparison with coronary angiography and intravascular ultrasound. | journal=Circulation | year= 1999 | volume= 100 | issue= 5 | pages= 509-15 | pmid=10430765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10430765 }} </ref> The sensitivity, specificity, positive predictive value and negative predictive value of DSE for the diagnosis of CAV in comparison to angiography has been found to be ranging from 65% to 95%, 55% to 95%, 69% to 92%, and 71% to 92%, respectively.<ref name="pmid23680373">{{cite journal| author=Pollack A, Nazif T, Mancini D, Weisz G| title=Detection and imaging of cardiac allograft vasculopathy. | journal=JACC Cardiovasc Imaging | year= 2013 | volume= 6 | issue= 5 | pages= 613-23 | pmid=23680373 | doi=10.1016/j.jcmg.2013.03.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23680373 }} </ref>

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy other imaging findings

2014-09-28T17:33:53Z

Raviteja Reddy Guddeti: /* Dobutamine Stress Echocardiogram */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Non-invasive testing by stress electrocardiography is of limited use in the diagnosis of cardiac allograft vasculopathy (CAV) due to high frequency of baseline electrocardiographic abnormalities and the reduced exercise tolerance in heart transplant recipients. Therefore adjunctive imaging in the form of stress echocardiogram and radionuclide imaging to improve sensitivity and specificity has been used for this purpose.

==Other Imaging Findings==
===Dobutamine Stress Echocardiogram===
Akosah et al first reported the use of dobutamine stress echocardiogram (DSE) in the diagnosis of CAV.<ref name="pmid7865509">{{cite journal| author=Akosah KO, Mohanty PK, Funai JT, Jesse RL, Minisi AJ, Crandall CW et al.| title=Noninvasive detection of transplant coronary artery disease by dobutamine stress echocardiography. | journal=J Heart Lung Transplant | year= 1994 | volume= 13 | issue= 6 | pages= 1024-38 | pmid=7865509 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7865509 }} </ref> The study demonstrated the sensitivity, specificity, negative predictive value and positive predictive value of DSE to be 95%, 55%, 69% and 92% respectively. Subsequently several studies compared the efficacy of DSE in combination with coronary angiography and with or without intravascular ultrasound for detecting the presence and severity of CAV.<ref name="pmid9563602">{{cite journal| author=Derumeaux G, Redonnet M, Soyer R, Cribier A, Letac B| title=Assessment of the progression of cardiac allograft vasculopathy by dobutamine stress echocardiography. | journal=J Heart Lung Transplant | year= 1998 | volume= 17 | issue= 3 | pages= 259-67 | pmid=9563602 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9563602 }} </ref><ref name="pmid9626841">{{cite journal| author=Akosah KO, McDaniel S, Hanrahan JS, Mohanty PK| title=Dobutamine stress echocardiography early after heart transplantation predicts development of allograft coronary artery disease and outcome. | journal=J Am Coll Cardiol | year= 1998 | volume= 31 | issue= 7 | pages= 1607-14 | pmid=9626841 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9626841 }} </ref><ref name="pmid10430765">{{cite journal| author=Spes CH, Klauss V, Mudra H, Schnaack SD, Tammen AR, Rieber J et al.| title=Diagnostic and prognostic value of serial dobutamine stress echocardiography for noninvasive assessment of cardiac allograft vasculopathy: a comparison with coronary angiography and intravascular ultrasound. | journal=Circulation | year= 1999 | volume= 100 | issue= 5 | pages= 509-15 | pmid=10430765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10430765 }} </ref><ref name="pmid8712138">{{cite journal| author=Spes CH, Mudra H, Schnaack SD, Klauss V, Reichle FM, Uberfuhr P et al.| title=Dobutamine stress echocardiography for noninvasive diagnosis of cardiac allograft vasculopathy: a comparison with angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 1996 | volume= 78 | issue= 2 | pages= 168-74 | pmid=8712138 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8712138 }} </ref><ref name="pmid7759721">{{cite journal| author=Derumeaux G, Redonnet M, Mouton-Schleifer D, Bessou JP, Cribier A, Saoudi N et al.| title=Dobutamine stress echocardiography in orthotopic heart transplant recipients. VACOMED Research Group. | journal=J Am Coll Cardiol | year= 1995 | volume= 25 | issue= 7 | pages= 1665-72 | pmid=7759721 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7759721 }} </ref> Spes et al, in a study to evaluate the value of DSE for non-invasive diagnosis of CAV compared with coronary angiography and IVUS, demonstrated that regional myocardial dysfunction as assessed by DSE correlated well with IVUS-derived evidence of moderate to severe intimal hyperplasia. The study concluded that DSE could be used as a feasible alternative noninvasive diagnostic method to diagnose CAV and may indeed reduce the need for frequent invasive screening by coronary angiography.<ref name="pmid8712138">{{cite journal| author=Spes CH, Mudra H, Schnaack SD, Klauss V, Reichle FM, Uberfuhr P et al.| title=Dobutamine stress echocardiography for noninvasive diagnosis of cardiac allograft vasculopathy: a comparison with angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 1996 | volume= 78 | issue= 2 | pages= 168-74 | pmid=8712138 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8712138 }} </ref> In a similar study by the same group to determine the prognostic value of DSE in CAV compared with coronary angiography and IVUS it was found that the prognostic value of DSE was comparable to that of angiography and IVUS.<ref name="pmid10430765">{{cite journal| author=Spes CH, Klauss V, Mudra H, Schnaack SD, Tammen AR, Rieber J et al.| title=Diagnostic and prognostic value of serial dobutamine stress echocardiography for noninvasive assessment of cardiac allograft vasculopathy: a comparison with coronary angiography and intravascular ultrasound. | journal=Circulation | year= 1999 | volume= 100 | issue= 5 | pages= 509-15 | pmid=10430765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10430765 }} </ref>

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy other imaging findings

2014-09-28T17:29:32Z

Raviteja Reddy Guddeti: /* Dobutamine Stress Echocardiogram */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Non-invasive testing by stress electrocardiography is of limited use in the diagnosis of cardiac allograft vasculopathy (CAV) due to high frequency of baseline electrocardiographic abnormalities and the reduced exercise tolerance in heart transplant recipients. Therefore adjunctive imaging in the form of stress echocardiogram and radionuclide imaging to improve sensitivity and specificity has been used for this purpose.

==Other Imaging Findings==
===Dobutamine Stress Echocardiogram===
Akosah et al first reported the use of dobutamine stress echocardiogram (DSE) in the diagnosis of CAV.<ref name="pmid7865509">{{cite journal| author=Akosah KO, Mohanty PK, Funai JT, Jesse RL, Minisi AJ, Crandall CW et al.| title=Noninvasive detection of transplant coronary artery disease by dobutamine stress echocardiography. | journal=J Heart Lung Transplant | year= 1994 | volume= 13 | issue= 6 | pages= 1024-38 | pmid=7865509 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7865509 }} </ref> The study demonstrated the sensitivity, specificity, negative predictive value and positive predictive value of DSE to be 95%, 55%, 69% and 92% respectively. Subsequently several studies compared the efficacy of DSE in combination with coronary angiography and with or without intravascular ultrasound for detecting the presence and severity of CAV.<ref name="pmid9563602">{{cite journal| author=Derumeaux G, Redonnet M, Soyer R, Cribier A, Letac B| title=Assessment of the progression of cardiac allograft vasculopathy by dobutamine stress echocardiography. | journal=J Heart Lung Transplant | year= 1998 | volume= 17 | issue= 3 | pages= 259-67 | pmid=9563602 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9563602 }} </ref><ref name="pmid9626841">{{cite journal| author=Akosah KO, McDaniel S, Hanrahan JS, Mohanty PK| title=Dobutamine stress echocardiography early after heart transplantation predicts development of allograft coronary artery disease and outcome. | journal=J Am Coll Cardiol | year= 1998 | volume= 31 | issue= 7 | pages= 1607-14 | pmid=9626841 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9626841 }} </ref><ref name="pmid10430765">{{cite journal| author=Spes CH, Klauss V, Mudra H, Schnaack SD, Tammen AR, Rieber J et al.| title=Diagnostic and prognostic value of serial dobutamine stress echocardiography for noninvasive assessment of cardiac allograft vasculopathy: a comparison with coronary angiography and intravascular ultrasound. | journal=Circulation | year= 1999 | volume= 100 | issue= 5 | pages= 509-15 | pmid=10430765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10430765 }} </ref><ref name="pmid8712138">{{cite journal| author=Spes CH, Mudra H, Schnaack SD, Klauss V, Reichle FM, Uberfuhr P et al.| title=Dobutamine stress echocardiography for noninvasive diagnosis of cardiac allograft vasculopathy: a comparison with angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 1996 | volume= 78 | issue= 2 | pages= 168-74 | pmid=8712138 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8712138 }} </ref><ref name="pmid7759721">{{cite journal| author=Derumeaux G, Redonnet M, Mouton-Schleifer D, Bessou JP, Cribier A, Saoudi N et al.| title=Dobutamine stress echocardiography in orthotopic heart transplant recipients. VACOMED Research Group. | journal=J Am Coll Cardiol | year= 1995 | volume= 25 | issue= 7 | pages= 1665-72 | pmid=7759721 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7759721 }} </ref> Spes et al, in a study to evaluate the value of DSE for non-invasive diagnosis of CAV compared with coronary angiography and IVUS, demonstrated that regional myocardial dysfunction as assessed by DSE correlated well with IVUS-derived evidence of moderate to severe intimal hyperplasia. The study concluded that DSE could be used as a feasible alternative noninvasive diagnostic method to diagnose CAV and may indeed reduce the need for frequent invasive screening by coronary angiography.<ref name="pmid8712138">{{cite journal| author=Spes CH, Mudra H, Schnaack SD, Klauss V, Reichle FM, Uberfuhr P et al.| title=Dobutamine stress echocardiography for noninvasive diagnosis of cardiac allograft vasculopathy: a comparison with angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 1996 | volume= 78 | issue= 2 | pages= 168-74 | pmid=8712138 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8712138 }} </ref>

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy other imaging findings

2014-09-28T17:20:51Z

Raviteja Reddy Guddeti: /* Dobutamine Stress Echocardiogram */

Cardiac allograft vasculopathy other imaging findings

2014-09-28T17:19:45Z

Raviteja Reddy Guddeti: /* Dobutamine Stress Echocardiogram */

Cardiac allograft vasculopathy other imaging findings

2014-09-28T17:18:29Z

Raviteja Reddy Guddeti: /* Other Imaging Findings */

Cardiac allograft vasculopathy other imaging findings

2014-09-28T17:17:28Z

Raviteja Reddy Guddeti: /* Dobutamine Stress Echocardiogram */

Cardiac allograft vasculopathy other imaging findings

2014-09-28T17:16:18Z

Raviteja Reddy Guddeti: /* Dobutamine Stress Echocardiogram */

Cardiac allograft vasculopathy other imaging findings

2014-09-28T17:11:19Z

Raviteja Reddy Guddeti: /* Dobutamine Stress Echocardiogram */

Cardiac allograft vasculopathy other imaging findings

2014-09-28T17:07:47Z

Raviteja Reddy Guddeti: Created page with "__NOTOC__ {{Cardiac allograft vasculopathy}} {{CMG}}; {{AE}} {{AN}}; {{RT}} ==Overview== Non-invasive testing by stress electrocardiography is of limited use in the diagnosis..."

Cardiac allograft vasculopathy intravascular ultrasound

2014-08-12T21:56:31Z

Raviteja Reddy Guddeti: /* Advantages */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Since the early manifestations of cardiac allograft vasculopathy (CAV) are confined to the arterial wall, use of [[intravascular ultrasound]] ([[IVUS]]) makes it particularly useful in assessing graft [[coronary arteries]] early after [[heart transplantation]]. Its relatively higher [[sensitivity]] in defining arterial wall changes has shed light on important advances in the understanding of the natural history, distribution, and morphology of CAV.

==Intravascular Ultrasound==
===Grayscale IVUS===
Good tissue penetration of up to 10 mm allows accurate assessment of the arterial wall and plaque volume changes. Serial IVUS examinations starting early after heart transplantation will allow best assessment of percent change plaque volume. Evidence of CAV is found in 80% of the patients within one year of heart transplantation.<ref name="pmid8613612">{{cite journal| author=Tuzcu EM, De Franco AC, Goormastic M, Hobbs RE, Rincon G, Bott-Silverman C et al.| title=Dichotomous pattern of coronary atherosclerosis 1 to 9 years after transplantation: insights from systematic intravascular ultrasound imaging. | journal=J Am Coll Cardiol | year= 1996 | volume= 27 | issue= 4 | pages= 839-46 | pmid=8613612 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8613612 }} </ref> Similar conclusions were made by St Goar et al in a study comparing in vivo intracoronary ultrasound with angiography in cardiac transplant recipients.<ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref> In a 2010 study by Cale et al it was concluded that routine use of IVUS may lead to higher detection rates of sub-angiographic CAV.<ref name="pmid20545250">{{cite journal| author=Calé R, Almeida M, Rebocho MJ, Aguiar C, Sousa P, Brito J et al.| title=The value of routine intracoronary ultrasound to assess coronary artery disease in cardiac allograft recipients. | journal=Rev Port Cardiol | year= 2010 | volume= 29 | issue= 2 | pages= 231-41 | pmid=20545250 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20545250 }} </ref> Rapidly progressive CAV is defined as intimal thickness of ≥0.5 mm with in one year of heart transplantation.

Stanford classification:
{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Class}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Intimal Thickening}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class 0 (none)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| No intimal thickening
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class I (trivial)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class II (mild)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 mm and >180° circumference or 0.3 to 0.5 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class III (moderate)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 to 0.5 mm and >180° circumference or intimal thickening 0.5 to 1 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class IV (severe)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening >0.5 mm and >180° circumference or intimal thickening >1 mm
|}

===Virtual Histology-IVUS===
Virtual histology-intravascular ultrasound (VH-IVUS) allows in vivo characterization of different plaque morphologies [fibrous (green), fibrofatty (light green), dense calcium (white), and necrotic core (red)] by using spectral analysis of IVUS radiofrequency data.<ref name="pmid12390948">{{cite journal| author=Nair A, Kuban BD, Tuzcu EM, Schoenhagen P, Nissen SE, Vince DG| title=Coronary plaque classification with intravascular ultrasound radiofrequency data analysis. | journal=Circulation | year= 2002 | volume= 106 | issue= 17 | pages= 2200-6 | pmid=12390948 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12390948 }} </ref> Depending on the percent necrotic core and dense calcium coronary plaques can be classified into inflammatory, defined as necrotic core plus dense calcium ≥30% and non-inflammatory, defined as necrotic core plus dense calcium <30% of the total plaque volume. In a validation study of in vivo virtual histology compared with in vitro histopathology Nasu K et al demonstrated that VH-IVUS data correlated with histopathology with high accuracy.<ref name="pmid16781367">{{cite journal| author=Nasu K, Tsuchikane E, Katoh O, Vince DG, Virmani R, Surmely JF et al.| title=Accuracy of in vivo coronary plaque morphology assessment: a validation study of in vivo virtual histology compared with in vitro histopathology. | journal=J Am Coll Cardiol | year= 2006 | volume= 47 | issue= 12 | pages= 2405-12 | pmid=16781367 | doi=10.1016/j.jacc.2006.02.044 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16781367 }} </ref>

Using VH-IVUS in heart transplant recipients, Raichlin et al demonstrated that higher inflammatory burden of CAV atherosclerotic plaque burden is associated with early recurrent rejection and higher subsequent progression of CAV. This study also signifies the role of inflammation in the pathogenesis of CAV.<ref name="pmid19358941">{{cite journal| author=Raichlin E, Bae JH, Kushwaha SS, Lennon RJ, Prasad A, Rihal CS et al.| title=Inflammatory burden of cardiac allograft coronary atherosclerotic plaque is associated with early recurrent cellular rejection and predicts a higher risk of vasculopathy progression. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= 1279-86 | pmid=19358941 | doi=10.1016/j.jacc.2008.12.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358941 }} </ref> This concludes that VH-IVUS may provide supplemental information to coronary angiography in identifying at risk patients for future progression of CAV.

====Advantages====
* Safe<ref name="pmid11023244">{{cite journal| author=Bocksch W, Wellnhofer E, Schartl M, Dreysse S, Klimek W, Franke R et al.| title=Reproducibility of serial intravascular ultrasound measurements in patients with angiographically silent coronary artery disease after heart transplantation. | journal=Coron Artery Dis | year= 2000 | volume= 11 | issue= 7 | pages= 555-62 | pmid=11023244 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11023244 }} </ref>
* Relative higher sensitivity compared with coronary angiography<ref name="pmid11023244">{{cite journal| author=Bocksch W, Wellnhofer E, Schartl M, Dreysse S, Klimek W, Franke R et al.| title=Reproducibility of serial intravascular ultrasound measurements in patients with angiographically silent coronary artery disease after heart transplantation. | journal=Coron Artery Dis | year= 2000 | volume= 11 | issue= 7 | pages= 555-62 | pmid=11023244 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11023244 }} </ref> It is now considered gold standard for early diagnosis of CAV.
* Plaque tissue characterization<ref name="pmid19358941">{{cite journal| author=Raichlin E, Bae JH, Kushwaha SS, Lennon RJ, Prasad A, Rihal CS et al.| title=Inflammatory burden of cardiac allograft coronary atherosclerotic plaque is associated with early recurrent cellular rejection and predicts a higher risk of vasculopathy progression. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= 1279-86 | pmid=19358941 | doi=10.1016/j.jacc.2008.12.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358941 }} </ref>
* Serial IVUS examinations starting early after heart transplantation my help differentiate native atherosclerosis from CAV.

====Limitation====
* [[IVUS]] is usually performed at the time of [[coronary angiography]]. This may lead to additional time of sedation and mildly increased procedural risks.
* Ability to visualize only the proximal segments of the coronary arteries
* Limited availability, training of personnel involved and use of specialized catheters may increase healthcare costs
* Lower resolution compared with [[optical coherence tomography]] ([[OCT]])

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy intravascular ultrasound

2014-08-12T21:51:13Z

Raviteja Reddy Guddeti: /* Grayscale IVUS */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Since the early manifestations of cardiac allograft vasculopathy (CAV) are confined to the arterial wall, use of [[intravascular ultrasound]] ([[IVUS]]) makes it particularly useful in assessing graft [[coronary arteries]] early after [[heart transplantation]]. Its relatively higher [[sensitivity]] in defining arterial wall changes has shed light on important advances in the understanding of the natural history, distribution, and morphology of CAV.

==Intravascular Ultrasound==
===Grayscale IVUS===
Good tissue penetration of up to 10 mm allows accurate assessment of the arterial wall and plaque volume changes. Serial IVUS examinations starting early after heart transplantation will allow best assessment of percent change plaque volume. Evidence of CAV is found in 80% of the patients within one year of heart transplantation.<ref name="pmid8613612">{{cite journal| author=Tuzcu EM, De Franco AC, Goormastic M, Hobbs RE, Rincon G, Bott-Silverman C et al.| title=Dichotomous pattern of coronary atherosclerosis 1 to 9 years after transplantation: insights from systematic intravascular ultrasound imaging. | journal=J Am Coll Cardiol | year= 1996 | volume= 27 | issue= 4 | pages= 839-46 | pmid=8613612 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8613612 }} </ref> Similar conclusions were made by St Goar et al in a study comparing in vivo intracoronary ultrasound with angiography in cardiac transplant recipients.<ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref> In a 2010 study by Cale et al it was concluded that routine use of IVUS may lead to higher detection rates of sub-angiographic CAV.<ref name="pmid20545250">{{cite journal| author=Calé R, Almeida M, Rebocho MJ, Aguiar C, Sousa P, Brito J et al.| title=The value of routine intracoronary ultrasound to assess coronary artery disease in cardiac allograft recipients. | journal=Rev Port Cardiol | year= 2010 | volume= 29 | issue= 2 | pages= 231-41 | pmid=20545250 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20545250 }} </ref> Rapidly progressive CAV is defined as intimal thickness of ≥0.5 mm with in one year of heart transplantation.

Stanford classification:
{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Class}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Intimal Thickening}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class 0 (none)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| No intimal thickening
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class I (trivial)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class II (mild)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 mm and >180° circumference or 0.3 to 0.5 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class III (moderate)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 to 0.5 mm and >180° circumference or intimal thickening 0.5 to 1 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class IV (severe)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening >0.5 mm and >180° circumference or intimal thickening >1 mm
|}

===Virtual Histology-IVUS===
Virtual histology-intravascular ultrasound (VH-IVUS) allows in vivo characterization of different plaque morphologies [fibrous (green), fibrofatty (light green), dense calcium (white), and necrotic core (red)] by using spectral analysis of IVUS radiofrequency data.<ref name="pmid12390948">{{cite journal| author=Nair A, Kuban BD, Tuzcu EM, Schoenhagen P, Nissen SE, Vince DG| title=Coronary plaque classification with intravascular ultrasound radiofrequency data analysis. | journal=Circulation | year= 2002 | volume= 106 | issue= 17 | pages= 2200-6 | pmid=12390948 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12390948 }} </ref> Depending on the percent necrotic core and dense calcium coronary plaques can be classified into inflammatory, defined as necrotic core plus dense calcium ≥30% and non-inflammatory, defined as necrotic core plus dense calcium <30% of the total plaque volume. In a validation study of in vivo virtual histology compared with in vitro histopathology Nasu K et al demonstrated that VH-IVUS data correlated with histopathology with high accuracy.<ref name="pmid16781367">{{cite journal| author=Nasu K, Tsuchikane E, Katoh O, Vince DG, Virmani R, Surmely JF et al.| title=Accuracy of in vivo coronary plaque morphology assessment: a validation study of in vivo virtual histology compared with in vitro histopathology. | journal=J Am Coll Cardiol | year= 2006 | volume= 47 | issue= 12 | pages= 2405-12 | pmid=16781367 | doi=10.1016/j.jacc.2006.02.044 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16781367 }} </ref>

Using VH-IVUS in heart transplant recipients, Raichlin et al demonstrated that higher inflammatory burden of CAV atherosclerotic plaque burden is associated with early recurrent rejection and higher subsequent progression of CAV. This study also signifies the role of inflammation in the pathogenesis of CAV.<ref name="pmid19358941">{{cite journal| author=Raichlin E, Bae JH, Kushwaha SS, Lennon RJ, Prasad A, Rihal CS et al.| title=Inflammatory burden of cardiac allograft coronary atherosclerotic plaque is associated with early recurrent cellular rejection and predicts a higher risk of vasculopathy progression. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= 1279-86 | pmid=19358941 | doi=10.1016/j.jacc.2008.12.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358941 }} </ref> This concludes that VH-IVUS may provide supplemental information to coronary angiography in identifying at risk patients for future progression of CAV.

====Advantages====
* Safe<ref name="pmid11023244">{{cite journal| author=Bocksch W, Wellnhofer E, Schartl M, Dreysse S, Klimek W, Franke R et al.| title=Reproducibility of serial intravascular ultrasound measurements in patients with angiographically silent coronary artery disease after heart transplantation. | journal=Coron Artery Dis | year= 2000 | volume= 11 | issue= 7 | pages= 555-62 | pmid=11023244 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11023244 }} </ref>
* Relative higher sensitivity compared with coronary angiography<ref name="pmid11023244">{{cite journal| author=Bocksch W, Wellnhofer E, Schartl M, Dreysse S, Klimek W, Franke R et al.| title=Reproducibility of serial intravascular ultrasound measurements in patients with angiographically silent coronary artery disease after heart transplantation. | journal=Coron Artery Dis | year= 2000 | volume= 11 | issue= 7 | pages= 555-62 | pmid=11023244 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11023244 }} </ref> It is now considered gold standard for early diagnosis of CAV.
* Plaque tissue characterization<ref name="pmid19358941">{{cite journal| author=Raichlin E, Bae JH, Kushwaha SS, Lennon RJ, Prasad A, Rihal CS et al.| title=Inflammatory burden of cardiac allograft coronary atherosclerotic plaque is associated with early recurrent cellular rejection and predicts a higher risk of vasculopathy progression. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= 1279-86 | pmid=19358941 | doi=10.1016/j.jacc.2008.12.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358941 }} </ref>

====Limitation====
* [[IVUS]] is usually performed at the time of [[coronary angiography]]. This may lead to additional time of sedation and mildly increased procedural risks.
* Ability to visualize only the proximal segments of the coronary arteries
* Limited availability, training of personnel involved and use of specialized catheters may increase healthcare costs
* Lower resolution compared with [[optical coherence tomography]] ([[OCT]])

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy intravascular ultrasound

2014-08-12T21:44:48Z

Raviteja Reddy Guddeti: /* Grayscale IVUS */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Since the early manifestations of cardiac allograft vasculopathy (CAV) are confined to the arterial wall, use of [[intravascular ultrasound]] ([[IVUS]]) makes it particularly useful in assessing graft [[coronary arteries]] early after [[heart transplantation]]. Its relatively higher [[sensitivity]] in defining arterial wall changes has shed light on important advances in the understanding of the natural history, distribution, and morphology of CAV.

==Intravascular Ultrasound==
===Grayscale IVUS===
Good tissue penetration of up to 10 mm allows accurate assessment of the arterial wall and plaque volume changes. Serial IVUS examinations starting early after heart transplantation will allow best assessment of percent change plaque volume. Evidence of CAV is found in 80% of the patients within one year of heart transplantation.<ref name="pmid8613612">{{cite journal| author=Tuzcu EM, De Franco AC, Goormastic M, Hobbs RE, Rincon G, Bott-Silverman C et al.| title=Dichotomous pattern of coronary atherosclerosis 1 to 9 years after transplantation: insights from systematic intravascular ultrasound imaging. | journal=J Am Coll Cardiol | year= 1996 | volume= 27 | issue= 4 | pages= 839-46 | pmid=8613612 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8613612 }} </ref> Similar conclusions were made by St Goar et al in a study comparing in vivo intracoronary ultrasound with angiography in cardiac transplant recipients.<ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref> Rapidly progressive CAV is defined as intimal thickness of ≥0.5 mm with in one year of heart transplantation.

Stanford classification:
{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Class}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Intimal Thickening}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class 0 (none)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| No intimal thickening
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class I (trivial)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class II (mild)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 mm and >180° circumference or 0.3 to 0.5 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class III (moderate)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 to 0.5 mm and >180° circumference or intimal thickening 0.5 to 1 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class IV (severe)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening >0.5 mm and >180° circumference or intimal thickening >1 mm
|}

===Virtual Histology-IVUS===
Virtual histology-intravascular ultrasound (VH-IVUS) allows in vivo characterization of different plaque morphologies [fibrous (green), fibrofatty (light green), dense calcium (white), and necrotic core (red)] by using spectral analysis of IVUS radiofrequency data.<ref name="pmid12390948">{{cite journal| author=Nair A, Kuban BD, Tuzcu EM, Schoenhagen P, Nissen SE, Vince DG| title=Coronary plaque classification with intravascular ultrasound radiofrequency data analysis. | journal=Circulation | year= 2002 | volume= 106 | issue= 17 | pages= 2200-6 | pmid=12390948 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12390948 }} </ref> Depending on the percent necrotic core and dense calcium coronary plaques can be classified into inflammatory, defined as necrotic core plus dense calcium ≥30% and non-inflammatory, defined as necrotic core plus dense calcium <30% of the total plaque volume. In a validation study of in vivo virtual histology compared with in vitro histopathology Nasu K et al demonstrated that VH-IVUS data correlated with histopathology with high accuracy.<ref name="pmid16781367">{{cite journal| author=Nasu K, Tsuchikane E, Katoh O, Vince DG, Virmani R, Surmely JF et al.| title=Accuracy of in vivo coronary plaque morphology assessment: a validation study of in vivo virtual histology compared with in vitro histopathology. | journal=J Am Coll Cardiol | year= 2006 | volume= 47 | issue= 12 | pages= 2405-12 | pmid=16781367 | doi=10.1016/j.jacc.2006.02.044 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16781367 }} </ref>

Using VH-IVUS in heart transplant recipients, Raichlin et al demonstrated that higher inflammatory burden of CAV atherosclerotic plaque burden is associated with early recurrent rejection and higher subsequent progression of CAV. This study also signifies the role of inflammation in the pathogenesis of CAV.<ref name="pmid19358941">{{cite journal| author=Raichlin E, Bae JH, Kushwaha SS, Lennon RJ, Prasad A, Rihal CS et al.| title=Inflammatory burden of cardiac allograft coronary atherosclerotic plaque is associated with early recurrent cellular rejection and predicts a higher risk of vasculopathy progression. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= 1279-86 | pmid=19358941 | doi=10.1016/j.jacc.2008.12.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358941 }} </ref> This concludes that VH-IVUS may provide supplemental information to coronary angiography in identifying at risk patients for future progression of CAV.

====Advantages====
* Safe<ref name="pmid11023244">{{cite journal| author=Bocksch W, Wellnhofer E, Schartl M, Dreysse S, Klimek W, Franke R et al.| title=Reproducibility of serial intravascular ultrasound measurements in patients with angiographically silent coronary artery disease after heart transplantation. | journal=Coron Artery Dis | year= 2000 | volume= 11 | issue= 7 | pages= 555-62 | pmid=11023244 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11023244 }} </ref>
* Relative higher sensitivity compared with coronary angiography<ref name="pmid11023244">{{cite journal| author=Bocksch W, Wellnhofer E, Schartl M, Dreysse S, Klimek W, Franke R et al.| title=Reproducibility of serial intravascular ultrasound measurements in patients with angiographically silent coronary artery disease after heart transplantation. | journal=Coron Artery Dis | year= 2000 | volume= 11 | issue= 7 | pages= 555-62 | pmid=11023244 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11023244 }} </ref> It is now considered gold standard for early diagnosis of CAV.
* Plaque tissue characterization<ref name="pmid19358941">{{cite journal| author=Raichlin E, Bae JH, Kushwaha SS, Lennon RJ, Prasad A, Rihal CS et al.| title=Inflammatory burden of cardiac allograft coronary atherosclerotic plaque is associated with early recurrent cellular rejection and predicts a higher risk of vasculopathy progression. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= 1279-86 | pmid=19358941 | doi=10.1016/j.jacc.2008.12.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358941 }} </ref>

====Limitation====
* [[IVUS]] is usually performed at the time of [[coronary angiography]]. This may lead to additional time of sedation and mildly increased procedural risks.
* Ability to visualize only the proximal segments of the coronary arteries
* Limited availability, training of personnel involved and use of specialized catheters may increase healthcare costs
* Lower resolution compared with [[optical coherence tomography]] ([[OCT]])

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy intravascular ultrasound

2014-08-12T21:36:56Z

Raviteja Reddy Guddeti: /* Advantages */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Since the early manifestations of cardiac allograft vasculopathy (CAV) are confined to the arterial wall, use of [[intravascular ultrasound]] ([[IVUS]]) makes it particularly useful in assessing graft [[coronary arteries]] early after [[heart transplantation]]. Its relatively higher [[sensitivity]] in defining arterial wall changes has shed light on important advances in the understanding of the natural history, distribution, and morphology of CAV.

==Intravascular Ultrasound==
===Grayscale IVUS===
Good tissue penetration of up to 10 mm allows accurate assessment of the arterial wall and plaque volume changes. Serial IVUS examinations starting early after heart transplantation will allow best assessment of percent change plaque volume. Evidence of CAV is found in 80% of the patients within one year of heart transplantation.<ref name="pmid8613612">{{cite journal| author=Tuzcu EM, De Franco AC, Goormastic M, Hobbs RE, Rincon G, Bott-Silverman C et al.| title=Dichotomous pattern of coronary atherosclerosis 1 to 9 years after transplantation: insights from systematic intravascular ultrasound imaging. | journal=J Am Coll Cardiol | year= 1996 | volume= 27 | issue= 4 | pages= 839-46 | pmid=8613612 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8613612 }} </ref> Rapidly progressive CAV is defined as intimal thickness of ≥0.5 mm with in one year of heart transplantation.

Stanford classification:
{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Class}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Intimal Thickening}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class 0 (none)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| No intimal thickening
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class I (trivial)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class II (mild)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 mm and >180° circumference or 0.3 to 0.5 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class III (moderate)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 to 0.5 mm and >180° circumference or intimal thickening 0.5 to 1 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class IV (severe)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening >0.5 mm and >180° circumference or intimal thickening >1 mm
|}

===Virtual Histology-IVUS===
Virtual histology-intravascular ultrasound (VH-IVUS) allows in vivo characterization of different plaque morphologies [fibrous (green), fibrofatty (light green), dense calcium (white), and necrotic core (red)] by using spectral analysis of IVUS radiofrequency data.<ref name="pmid12390948">{{cite journal| author=Nair A, Kuban BD, Tuzcu EM, Schoenhagen P, Nissen SE, Vince DG| title=Coronary plaque classification with intravascular ultrasound radiofrequency data analysis. | journal=Circulation | year= 2002 | volume= 106 | issue= 17 | pages= 2200-6 | pmid=12390948 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12390948 }} </ref> Depending on the percent necrotic core and dense calcium coronary plaques can be classified into inflammatory, defined as necrotic core plus dense calcium ≥30% and non-inflammatory, defined as necrotic core plus dense calcium <30% of the total plaque volume. In a validation study of in vivo virtual histology compared with in vitro histopathology Nasu K et al demonstrated that VH-IVUS data correlated with histopathology with high accuracy.<ref name="pmid16781367">{{cite journal| author=Nasu K, Tsuchikane E, Katoh O, Vince DG, Virmani R, Surmely JF et al.| title=Accuracy of in vivo coronary plaque morphology assessment: a validation study of in vivo virtual histology compared with in vitro histopathology. | journal=J Am Coll Cardiol | year= 2006 | volume= 47 | issue= 12 | pages= 2405-12 | pmid=16781367 | doi=10.1016/j.jacc.2006.02.044 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16781367 }} </ref>

Using VH-IVUS in heart transplant recipients, Raichlin et al demonstrated that higher inflammatory burden of CAV atherosclerotic plaque burden is associated with early recurrent rejection and higher subsequent progression of CAV. This study also signifies the role of inflammation in the pathogenesis of CAV.<ref name="pmid19358941">{{cite journal| author=Raichlin E, Bae JH, Kushwaha SS, Lennon RJ, Prasad A, Rihal CS et al.| title=Inflammatory burden of cardiac allograft coronary atherosclerotic plaque is associated with early recurrent cellular rejection and predicts a higher risk of vasculopathy progression. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= 1279-86 | pmid=19358941 | doi=10.1016/j.jacc.2008.12.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358941 }} </ref> This concludes that VH-IVUS may provide supplemental information to coronary angiography in identifying at risk patients for future progression of CAV.

====Advantages====
* Safe<ref name="pmid11023244">{{cite journal| author=Bocksch W, Wellnhofer E, Schartl M, Dreysse S, Klimek W, Franke R et al.| title=Reproducibility of serial intravascular ultrasound measurements in patients with angiographically silent coronary artery disease after heart transplantation. | journal=Coron Artery Dis | year= 2000 | volume= 11 | issue= 7 | pages= 555-62 | pmid=11023244 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11023244 }} </ref>
* Relative higher sensitivity compared with coronary angiography<ref name="pmid11023244">{{cite journal| author=Bocksch W, Wellnhofer E, Schartl M, Dreysse S, Klimek W, Franke R et al.| title=Reproducibility of serial intravascular ultrasound measurements in patients with angiographically silent coronary artery disease after heart transplantation. | journal=Coron Artery Dis | year= 2000 | volume= 11 | issue= 7 | pages= 555-62 | pmid=11023244 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11023244 }} </ref> It is now considered gold standard for early diagnosis of CAV.
* Plaque tissue characterization<ref name="pmid19358941">{{cite journal| author=Raichlin E, Bae JH, Kushwaha SS, Lennon RJ, Prasad A, Rihal CS et al.| title=Inflammatory burden of cardiac allograft coronary atherosclerotic plaque is associated with early recurrent cellular rejection and predicts a higher risk of vasculopathy progression. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= 1279-86 | pmid=19358941 | doi=10.1016/j.jacc.2008.12.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358941 }} </ref>

====Limitation====
* [[IVUS]] is usually performed at the time of [[coronary angiography]]. This may lead to additional time of sedation and mildly increased procedural risks.
* Ability to visualize only the proximal segments of the coronary arteries
* Limited availability, training of personnel involved and use of specialized catheters may increase healthcare costs
* Lower resolution compared with [[optical coherence tomography]] ([[OCT]])

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy intravascular ultrasound

2014-08-12T21:09:02Z

Raviteja Reddy Guddeti: /* Limitation */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Since the early manifestations of cardiac allograft vasculopathy (CAV) are confined to the arterial wall, use of [[intravascular ultrasound]] ([[IVUS]]) makes it particularly useful in assessing graft [[coronary arteries]] early after [[heart transplantation]]. Its relatively higher [[sensitivity]] in defining arterial wall changes has shed light on important advances in the understanding of the natural history, distribution, and morphology of CAV.

==Intravascular Ultrasound==
===Grayscale IVUS===
Good tissue penetration of up to 10 mm allows accurate assessment of the arterial wall and plaque volume changes. Serial IVUS examinations starting early after heart transplantation will allow best assessment of percent change plaque volume. Evidence of CAV is found in 80% of the patients within one year of heart transplantation.<ref name="pmid8613612">{{cite journal| author=Tuzcu EM, De Franco AC, Goormastic M, Hobbs RE, Rincon G, Bott-Silverman C et al.| title=Dichotomous pattern of coronary atherosclerosis 1 to 9 years after transplantation: insights from systematic intravascular ultrasound imaging. | journal=J Am Coll Cardiol | year= 1996 | volume= 27 | issue= 4 | pages= 839-46 | pmid=8613612 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8613612 }} </ref> Rapidly progressive CAV is defined as intimal thickness of ≥0.5 mm with in one year of heart transplantation.

Stanford classification:
{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Class}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Intimal Thickening}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class 0 (none)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| No intimal thickening
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class I (trivial)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class II (mild)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 mm and >180° circumference or 0.3 to 0.5 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class III (moderate)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 to 0.5 mm and >180° circumference or intimal thickening 0.5 to 1 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class IV (severe)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening >0.5 mm and >180° circumference or intimal thickening >1 mm
|}

===Virtual Histology-IVUS===
Virtual histology-intravascular ultrasound (VH-IVUS) allows in vivo characterization of different plaque morphologies [fibrous (green), fibrofatty (light green), dense calcium (white), and necrotic core (red)] by using spectral analysis of IVUS radiofrequency data.<ref name="pmid12390948">{{cite journal| author=Nair A, Kuban BD, Tuzcu EM, Schoenhagen P, Nissen SE, Vince DG| title=Coronary plaque classification with intravascular ultrasound radiofrequency data analysis. | journal=Circulation | year= 2002 | volume= 106 | issue= 17 | pages= 2200-6 | pmid=12390948 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12390948 }} </ref> Depending on the percent necrotic core and dense calcium coronary plaques can be classified into inflammatory, defined as necrotic core plus dense calcium ≥30% and non-inflammatory, defined as necrotic core plus dense calcium <30% of the total plaque volume. In a validation study of in vivo virtual histology compared with in vitro histopathology Nasu K et al demonstrated that VH-IVUS data correlated with histopathology with high accuracy.<ref name="pmid16781367">{{cite journal| author=Nasu K, Tsuchikane E, Katoh O, Vince DG, Virmani R, Surmely JF et al.| title=Accuracy of in vivo coronary plaque morphology assessment: a validation study of in vivo virtual histology compared with in vitro histopathology. | journal=J Am Coll Cardiol | year= 2006 | volume= 47 | issue= 12 | pages= 2405-12 | pmid=16781367 | doi=10.1016/j.jacc.2006.02.044 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16781367 }} </ref>

Using VH-IVUS in heart transplant recipients, Raichlin et al demonstrated that higher inflammatory burden of CAV atherosclerotic plaque burden is associated with early recurrent rejection and higher subsequent progression of CAV. This study also signifies the role of inflammation in the pathogenesis of CAV.<ref name="pmid19358941">{{cite journal| author=Raichlin E, Bae JH, Kushwaha SS, Lennon RJ, Prasad A, Rihal CS et al.| title=Inflammatory burden of cardiac allograft coronary atherosclerotic plaque is associated with early recurrent cellular rejection and predicts a higher risk of vasculopathy progression. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= 1279-86 | pmid=19358941 | doi=10.1016/j.jacc.2008.12.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358941 }} </ref> This concludes that VH-IVUS may provide supplemental information to coronary angiography in identifying at risk patients for future progression of CAV.

====Advantages====
* Safe<ref name="pmid11023244">{{cite journal| author=Bocksch W, Wellnhofer E, Schartl M, Dreysse S, Klimek W, Franke R et al.| title=Reproducibility of serial intravascular ultrasound measurements in patients with angiographically silent coronary artery disease after heart transplantation. | journal=Coron Artery Dis | year= 2000 | volume= 11 | issue= 7 | pages= 555-62 | pmid=11023244 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11023244 }} </ref>
* Relative higher sensitivity compared with coronary angiography<ref name="pmid11023244">{{cite journal| author=Bocksch W, Wellnhofer E, Schartl M, Dreysse S, Klimek W, Franke R et al.| title=Reproducibility of serial intravascular ultrasound measurements in patients with angiographically silent coronary artery disease after heart transplantation. | journal=Coron Artery Dis | year= 2000 | volume= 11 | issue= 7 | pages= 555-62 | pmid=11023244 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11023244 }} </ref>
* Plaque tissue characterization<ref name="pmid19358941">{{cite journal| author=Raichlin E, Bae JH, Kushwaha SS, Lennon RJ, Prasad A, Rihal CS et al.| title=Inflammatory burden of cardiac allograft coronary atherosclerotic plaque is associated with early recurrent cellular rejection and predicts a higher risk of vasculopathy progression. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= 1279-86 | pmid=19358941 | doi=10.1016/j.jacc.2008.12.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358941 }} </ref>

====Limitation====
* [[IVUS]] is usually performed at the time of [[coronary angiography]]. This may lead to additional time of sedation and mildly increased procedural risks.
* Ability to visualize only the proximal segments of the coronary arteries
* Limited availability, training of personnel involved and use of specialized catheters may increase healthcare costs
* Lower resolution compared with [[optical coherence tomography]] ([[OCT]])

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy intravascular ultrasound

2014-08-12T21:08:21Z

Raviteja Reddy Guddeti: /* Intravascular Ultrasound */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Since the early manifestations of cardiac allograft vasculopathy (CAV) are confined to the arterial wall, use of [[intravascular ultrasound]] ([[IVUS]]) makes it particularly useful in assessing graft [[coronary arteries]] early after [[heart transplantation]]. Its relatively higher [[sensitivity]] in defining arterial wall changes has shed light on important advances in the understanding of the natural history, distribution, and morphology of CAV.

==Intravascular Ultrasound==
===Grayscale IVUS===
Good tissue penetration of up to 10 mm allows accurate assessment of the arterial wall and plaque volume changes. Serial IVUS examinations starting early after heart transplantation will allow best assessment of percent change plaque volume. Evidence of CAV is found in 80% of the patients within one year of heart transplantation.<ref name="pmid8613612">{{cite journal| author=Tuzcu EM, De Franco AC, Goormastic M, Hobbs RE, Rincon G, Bott-Silverman C et al.| title=Dichotomous pattern of coronary atherosclerosis 1 to 9 years after transplantation: insights from systematic intravascular ultrasound imaging. | journal=J Am Coll Cardiol | year= 1996 | volume= 27 | issue= 4 | pages= 839-46 | pmid=8613612 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8613612 }} </ref> Rapidly progressive CAV is defined as intimal thickness of ≥0.5 mm with in one year of heart transplantation.

Stanford classification:
{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Class}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Intimal Thickening}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class 0 (none)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| No intimal thickening
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class I (trivial)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class II (mild)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 mm and >180° circumference or 0.3 to 0.5 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class III (moderate)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 to 0.5 mm and >180° circumference or intimal thickening 0.5 to 1 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class IV (severe)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening >0.5 mm and >180° circumference or intimal thickening >1 mm
|}

===Virtual Histology-IVUS===
Virtual histology-intravascular ultrasound (VH-IVUS) allows in vivo characterization of different plaque morphologies [fibrous (green), fibrofatty (light green), dense calcium (white), and necrotic core (red)] by using spectral analysis of IVUS radiofrequency data.<ref name="pmid12390948">{{cite journal| author=Nair A, Kuban BD, Tuzcu EM, Schoenhagen P, Nissen SE, Vince DG| title=Coronary plaque classification with intravascular ultrasound radiofrequency data analysis. | journal=Circulation | year= 2002 | volume= 106 | issue= 17 | pages= 2200-6 | pmid=12390948 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12390948 }} </ref> Depending on the percent necrotic core and dense calcium coronary plaques can be classified into inflammatory, defined as necrotic core plus dense calcium ≥30% and non-inflammatory, defined as necrotic core plus dense calcium <30% of the total plaque volume. In a validation study of in vivo virtual histology compared with in vitro histopathology Nasu K et al demonstrated that VH-IVUS data correlated with histopathology with high accuracy.<ref name="pmid16781367">{{cite journal| author=Nasu K, Tsuchikane E, Katoh O, Vince DG, Virmani R, Surmely JF et al.| title=Accuracy of in vivo coronary plaque morphology assessment: a validation study of in vivo virtual histology compared with in vitro histopathology. | journal=J Am Coll Cardiol | year= 2006 | volume= 47 | issue= 12 | pages= 2405-12 | pmid=16781367 | doi=10.1016/j.jacc.2006.02.044 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16781367 }} </ref>

Using VH-IVUS in heart transplant recipients, Raichlin et al demonstrated that higher inflammatory burden of CAV atherosclerotic plaque burden is associated with early recurrent rejection and higher subsequent progression of CAV. This study also signifies the role of inflammation in the pathogenesis of CAV.<ref name="pmid19358941">{{cite journal| author=Raichlin E, Bae JH, Kushwaha SS, Lennon RJ, Prasad A, Rihal CS et al.| title=Inflammatory burden of cardiac allograft coronary atherosclerotic plaque is associated with early recurrent cellular rejection and predicts a higher risk of vasculopathy progression. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= 1279-86 | pmid=19358941 | doi=10.1016/j.jacc.2008.12.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358941 }} </ref> This concludes that VH-IVUS may provide supplemental information to coronary angiography in identifying at risk patients for future progression of CAV.

====Advantages====
* Safe<ref name="pmid11023244">{{cite journal| author=Bocksch W, Wellnhofer E, Schartl M, Dreysse S, Klimek W, Franke R et al.| title=Reproducibility of serial intravascular ultrasound measurements in patients with angiographically silent coronary artery disease after heart transplantation. | journal=Coron Artery Dis | year= 2000 | volume= 11 | issue= 7 | pages= 555-62 | pmid=11023244 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11023244 }} </ref>
* Relative higher sensitivity compared with coronary angiography<ref name="pmid11023244">{{cite journal| author=Bocksch W, Wellnhofer E, Schartl M, Dreysse S, Klimek W, Franke R et al.| title=Reproducibility of serial intravascular ultrasound measurements in patients with angiographically silent coronary artery disease after heart transplantation. | journal=Coron Artery Dis | year= 2000 | volume= 11 | issue= 7 | pages= 555-62 | pmid=11023244 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11023244 }} </ref>
* Plaque tissue characterization<ref name="pmid19358941">{{cite journal| author=Raichlin E, Bae JH, Kushwaha SS, Lennon RJ, Prasad A, Rihal CS et al.| title=Inflammatory burden of cardiac allograft coronary atherosclerotic plaque is associated with early recurrent cellular rejection and predicts a higher risk of vasculopathy progression. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= 1279-86 | pmid=19358941 | doi=10.1016/j.jacc.2008.12.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358941 }} </ref>

====Limitation====
* IVUS is usually performed at the time of coronary angiography. This may lead to additional time of sedation and mildly increased procedural risks.
* Ability to visualize only the proximal segments of the coronary arteries
* Limited availability, training of personnel involved and use of specialized catheters may increase healthcare costs
* Lower resolution compared with optical coherence tomography

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy intravascular ultrasound

2014-08-12T21:07:51Z

Raviteja Reddy Guddeti: /* Intravascular Ultrasound */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Since the early manifestations of cardiac allograft vasculopathy (CAV) are confined to the arterial wall, use of [[intravascular ultrasound]] ([[IVUS]]) makes it particularly useful in assessing graft [[coronary arteries]] early after [[heart transplantation]]. Its relatively higher [[sensitivity]] in defining arterial wall changes has shed light on important advances in the understanding of the natural history, distribution, and morphology of CAV.

==Intravascular Ultrasound==
===Grayscale IVUS===
Good tissue penetration of up to 10 mm allows accurate assessment of the arterial wall and plaque volume changes. Serial IVUS examinations starting early after heart transplantation will allow best assessment of percent change plaque volume. Evidence of CAV is found in 80% of the patients within one year of heart transplantation.<ref name="pmid8613612">{{cite journal| author=Tuzcu EM, De Franco AC, Goormastic M, Hobbs RE, Rincon G, Bott-Silverman C et al.| title=Dichotomous pattern of coronary atherosclerosis 1 to 9 years after transplantation: insights from systematic intravascular ultrasound imaging. | journal=J Am Coll Cardiol | year= 1996 | volume= 27 | issue= 4 | pages= 839-46 | pmid=8613612 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8613612 }} </ref> Rapidly progressive CAV is defined as intimal thickness of ≥0.5 mm with in one year of heart transplantation.

Stanford classification:
{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Class}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Intimal Thickening}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class 0 (none)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| No intimal thickening
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class I (trivial)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class II (mild)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 mm and >180° circumference or 0.3 to 0.5 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class III (moderate)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 to 0.5 mm and >180° circumference or intimal thickening 0.5 to 1 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class IV (severe)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening >0.5 mm and >180° circumference or intimal thickening >1 mm
|}

===Virtual Histology-IVUS===
Virtual histology-intravascular ultrasound (VH-IVUS) allows in vivo characterization of different plaque morphologies [fibrous (green), fibrofatty (light green), dense calcium (white), and necrotic core (red)] by using spectral analysis of IVUS radiofrequency data.<ref name="pmid12390948">{{cite journal| author=Nair A, Kuban BD, Tuzcu EM, Schoenhagen P, Nissen SE, Vince DG| title=Coronary plaque classification with intravascular ultrasound radiofrequency data analysis. | journal=Circulation | year= 2002 | volume= 106 | issue= 17 | pages= 2200-6 | pmid=12390948 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12390948 }} </ref> Depending on the percent necrotic core and dense calcium coronary plaques can be classified into inflammatory, defined as necrotic core plus dense calcium ≥30% and non-inflammatory, defined as necrotic core plus dense calcium <30% of the total plaque volume. In a validation study of in vivo virtual histology compared with in vitro histopathology Nasu K et al demonstrated that VH-IVUS data correlated with histopathology with high accuracy.<ref name="pmid16781367">{{cite journal| author=Nasu K, Tsuchikane E, Katoh O, Vince DG, Virmani R, Surmely JF et al.| title=Accuracy of in vivo coronary plaque morphology assessment: a validation study of in vivo virtual histology compared with in vitro histopathology. | journal=J Am Coll Cardiol | year= 2006 | volume= 47 | issue= 12 | pages= 2405-12 | pmid=16781367 | doi=10.1016/j.jacc.2006.02.044 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16781367 }} </ref>

Using VH-IVUS in heart transplant recipients, Raichlin et al demonstrated that higher inflammatory burden of CAV atherosclerotic plaque burden is associated with early recurrent rejection and higher subsequent progression of CAV. This study also signifies the role of inflammation in the pathogenesis of CAV.<ref name="pmid19358941">{{cite journal| author=Raichlin E, Bae JH, Kushwaha SS, Lennon RJ, Prasad A, Rihal CS et al.| title=Inflammatory burden of cardiac allograft coronary atherosclerotic plaque is associated with early recurrent cellular rejection and predicts a higher risk of vasculopathy progression. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= 1279-86 | pmid=19358941 | doi=10.1016/j.jacc.2008.12.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358941 }} </ref> This concludes that VH-IVUS may provide supplemental information to coronary angiography in identifying at risk patients for future progression of CAV.

====Advantages====
* Safe<ref name="pmid11023244">{{cite journal| author=Bocksch W, Wellnhofer E, Schartl M, Dreysse S, Klimek W, Franke R et al.| title=Reproducibility of serial intravascular ultrasound measurements in patients with angiographically silent coronary artery disease after heart transplantation. | journal=Coron Artery Dis | year= 2000 | volume= 11 | issue= 7 | pages= 555-62 | pmid=11023244 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11023244 }} </ref>
* Relative higher sensitivity compared with coronary angiography<ref name="pmid11023244">{{cite journal| author=Bocksch W, Wellnhofer E, Schartl M, Dreysse S, Klimek W, Franke R et al.| title=Reproducibility of serial intravascular ultrasound measurements in patients with angiographically silent coronary artery disease after heart transplantation. | journal=Coron Artery Dis | year= 2000 | volume= 11 | issue= 7 | pages= 555-62 | pmid=11023244 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11023244 }} </ref>
* Plaque tissue characterization<ref name="pmid19358941">{{cite journal| author=Raichlin E, Bae JH, Kushwaha SS, Lennon RJ, Prasad A, Rihal CS et al.| title=Inflammatory burden of cardiac allograft coronary atherosclerotic plaque is associated with early recurrent cellular rejection and predicts a higher risk of vasculopathy progression. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= 1279-86 | pmid=19358941 | doi=10.1016/j.jacc.2008.12.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358941 }} </ref>

====Limitation====
* IVUS is usually performed at the time of coronary angiography. This may lead to additional time of sedation and mildly increased procedural risks.
* Ability to visualize only the proximal segments of the coronary arteries
* Limited availability, training of personnel involved and use of specialized catheters may increase healthcare costs
* Lower resolution compared with optical coherence tomography

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy screening

2014-08-12T18:52:13Z

Raviteja Reddy Guddeti: /* Screening */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Cardiac allograft vasculopathy (CAV) is the leading cause of morbidity and mortality beyond the first year after [[heart transplantation]]. In most cardiac transplant centers [[coronary angiography]] currently remains the screening tool of choice for CAV. Early diagnosis is important as it may allow for alterations in medical therapy before the disease progresses to the stage where revascularization is required.

==Screening==
The 2010 International Society of Heart and Lung Transplant Guidelines for the care of heart transplant recipients recommend annual invasive [[coronary angiography]] as the screening tool of choice for CAV.<ref name="pmid20643330">{{cite journal| author=Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S et al.| title=The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 8 | pages= 914-56 | pmid=20643330 | doi=10.1016/j.healun.2010.05.034 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20643330 }} </ref> In most centers screening of graft coronary arteries for signs of CAV is usually performed six weeks after [[cardiac transplantation]] and then annually thereafter. In a retrospective study by Haddad et al it was reported that angiographic evidence of CAV increases by approximately 10% with every 2-year period after cardiac transplantation.<ref name="pmid16143236">{{cite journal| author=Haddad M, Pflugfelder PW, Guiraudon C, Novick RJ, McKenzie FN, Menkis A et al.| title=Angiographic, pathologic, and clinical relationships in coronary artery disease in cardiac allografts. | journal=J Heart Lung Transplant | year= 2005 | volume= 24 | issue= 9 | pages= 1218-25 | pmid=16143236 | doi=10.1016/j.healun.2004.08.016 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16143236 }} </ref> The principal advantages of coronary angiography are its wide acceptability, low cost compared with other novel imaging techniques, and ease of performance.<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref> Studies have shown that coronary angiography is 80% [[sensitivity|sensitive]] and 96% [[specificity|specific]] in detecting CAV.<ref name="pmid12973108">{{cite journal| author=Sharples LD, Jackson CH, Parameshwar J, Wallwork J, Large SR| title=Diagnostic accuracy of coronary angiography and risk factors for post-heart-transplant cardiac allograft vasculopathy. | journal=Transplantation | year= 2003 | volume= 76 | issue= 4 | pages= 679-82 | pmid=12973108 | doi=10.1097/01.TP.0000071200.37399.1D | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12973108 }} </ref><ref name="pmid16962473">{{cite journal| author=Störk S, Behr TM, Birk M, Uberfuhr P, Klauss V, Spes CH et al.| title=Assessment of cardiac allograft vasculopathy late after heart transplantation: when is coronary angiography necessary? | journal=J Heart Lung Transplant | year= 2006 | volume= 25 | issue= 9 | pages= 1103-8 | pmid=16962473 | doi=10.1016/j.healun.2006.05.009 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16962473 }} </ref>

Although coronary angiography is the preferred screening modality in many centers it lacks sensitivity in detecting early-CAV associated arterial wall changes. In early CAV due to positive arterial remodeling coronary vascular lumen is relatively preserved until negative remodeling occurs resulting in narrowing of the arterial lumen.<ref name="pmid11243599">{{cite journal| author=Nissen S| title=Coronary angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 2001 | volume= 87 | issue= 4A | pages= 15A-20A | pmid=11243599 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11243599 }} </ref> This positive remodeling is not detected by coronary angiography leading to an under-estimation of the extent of CAV.<ref name="pmid11243599">{{cite journal| author=Nissen S| title=Coronary angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 2001 | volume= 87 | issue= 4A | pages= 15A-20A | pmid=11243599 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11243599 }} </ref> Novel intracoronary imaging techniques such as [[intravascular ultrasound]] and [[optical coherence tomography]] have shown promising results in detecting these early-CAV associated coronary arterial wall changes.<ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref><ref name="pmid10363681">{{cite journal| author=Spes CH, Klauss V, Rieber J, Schnaack SD, Tammen AR, Uberfuhr P et al.| title=Functional and morphological findings in heart transplant recipients with a normal coronary angiogram: an analysis by dobutamine stress echocardiography, intracoronary Doppler and intravascular ultrasound. | journal=J Heart Lung Transplant | year= 1999 | volume= 18 | issue= 5 | pages= 391-8 | pmid=10363681 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10363681 }} </ref><ref name="pmid15862431">{{cite journal| author=Tuzcu EM, Kapadia SR, Sachar R, Ziada KM, Crowe TD, Feng J et al.| title=Intravascular ultrasound evidence of angiographically silent progression in coronary atherosclerosis predicts long-term morbidity and mortality after cardiac transplantation. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 9 | pages= 1538-42 | pmid=15862431 | doi=10.1016/j.jacc.2004.12.076 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15862431 }} </ref><ref name="pmid23499356">{{cite journal| author=Khandhar SJ, Yamamoto H, Teuteberg JJ, Shullo MA, Bezerra HG, Costa MA et al.| title=Optical coherence tomography for characterization of cardiac allograft vasculopathy after heart transplantation (OCTCAV study). | journal=J Heart Lung Transplant | year= 2013 | volume= 32 | issue= 6 | pages= 596-602 | pmid=23499356 | doi=10.1016/j.healun.2013.02.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23499356 }} </ref> Therefore supplementing these techniques to annual coronary angiography, especially in the initial years of heart transplantation may aid in identifying high-risk subjects and appropriately risk stratifying them. However, currently studies do not exist to support this strategy.

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy screening

2014-08-12T18:50:56Z

Raviteja Reddy Guddeti: /* Screening */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Cardiac allograft vasculopathy (CAV) is the leading cause of morbidity and mortality beyond the first year after [[heart transplantation]]. In most cardiac transplant centers [[coronary angiography]] currently remains the screening tool of choice for CAV. Early diagnosis is important as it may allow for alterations in medical therapy before the disease progresses to the stage where revascularization is required.

==Screening==
The 2010 International Society of Heart and Lung Transplant Guidelines for the care of heart transplant recipients recommend annual invasive [[coronary angiography]] as the screening tool of choice for CAV.<ref name="pmid20643330">{{cite journal| author=Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S et al.| title=The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 8 | pages= 914-56 | pmid=20643330 | doi=10.1016/j.healun.2010.05.034 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20643330 }} </ref> In most centers screening of graft coronary arteries for signs of CAV is usually performed six weeks after [[cardiac transplantation]] and then annually thereafter. In a retrospective study by Haddad et al it was reported that angiographic evidence of CAV increases by approximately 10% with every 2-year period after cardiac transplantation.<ref name="pmid16143236">{{cite journal| author=Haddad M, Pflugfelder PW, Guiraudon C, Novick RJ, McKenzie FN, Menkis A et al.| title=Angiographic, pathologic, and clinical relationships in coronary artery disease in cardiac allografts. | journal=J Heart Lung Transplant | year= 2005 | volume= 24 | issue= 9 | pages= 1218-25 | pmid=16143236 | doi=10.1016/j.healun.2004.08.016 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16143236 }} </ref> The principal advantages of coronary angiography are its wide acceptability, low cost compared with other novel imaging techniques, and ease of performance.<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref> Studies have shown that coronary angiography is 80% [[sensitivity|sensitive]] and 96% [[specificity|specific]] in detecting CAV.<ref name="pmid12973108">{{cite journal| author=Sharples LD, Jackson CH, Parameshwar J, Wallwork J, Large SR| title=Diagnostic accuracy of coronary angiography and risk factors for post-heart-transplant cardiac allograft vasculopathy. | journal=Transplantation | year= 2003 | volume= 76 | issue= 4 | pages= 679-82 | pmid=12973108 | doi=10.1097/01.TP.0000071200.37399.1D | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12973108 }} </ref><ref name="pmid16962473">{{cite journal| author=Störk S, Behr TM, Birk M, Uberfuhr P, Klauss V, Spes CH et al.| title=Assessment of cardiac allograft vasculopathy late after heart transplantation: when is coronary angiography necessary? | journal=J Heart Lung Transplant | year= 2006 | volume= 25 | issue= 9 | pages= 1103-8 | pmid=16962473 | doi=10.1016/j.healun.2006.05.009 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16962473 }} </ref>

Although coronary angiography is the preferred screening modality in many centers it lacks sensitivity in detecting early-CAV associated arterial wall changes. In early CAV due to positive arterial remodeling coronary vascular lumen is relatively preserved until negative remodeling occurs resulting in narrowing of the arterial lumen.<ref name="pmid11243599">{{cite journal| author=Nissen S| title=Coronary angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 2001 | volume= 87 | issue= 4A | pages= 15A-20A | pmid=11243599 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11243599 }} </ref> This positive remodeling is not detected by coronary angiography leading to an under-estimation of the extent of CAV.<ref name="pmid11243599">{{cite journal| author=Nissen S| title=Coronary angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 2001 | volume= 87 | issue= 4A | pages= 15A-20A | pmid=11243599 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11243599 }} </ref> Novel intracoronary imaging techniques such as [[intravascular ultrasound]] and [[optical coherence tomography]] have shown promising results in detecting these early-CAV associated coronary arterial wall changes.<ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref><ref name="pmid10363681">{{cite journal| author=Spes CH, Klauss V, Rieber J, Schnaack SD, Tammen AR, Uberfuhr P et al.| title=Functional and morphological findings in heart transplant recipients with a normal coronary angiogram: an analysis by dobutamine stress echocardiography, intracoronary Doppler and intravascular ultrasound. | journal=J Heart Lung Transplant | year= 1999 | volume= 18 | issue= 5 | pages= 391-8 | pmid=10363681 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10363681 }} </ref><ref name="pmid15862431">{{cite journal| author=Tuzcu EM, Kapadia SR, Sachar R, Ziada KM, Crowe TD, Feng J et al.| title=Intravascular ultrasound evidence of angiographically silent progression in coronary atherosclerosis predicts long-term morbidity and mortality after cardiac transplantation. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 9 | pages= 1538-42 | pmid=15862431 | doi=10.1016/j.jacc.2004.12.076 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15862431 }} </ref><ref name="pmid23499356">{{cite journal| author=Khandhar SJ, Yamamoto H, Teuteberg JJ, Shullo MA, Bezerra HG, Costa MA et al.| title=Optical coherence tomography for characterization of cardiac allograft vasculopathy after heart transplantation (OCTCAV study). | journal=J Heart Lung Transplant | year= 2013 | volume= 32 | issue= 6 | pages= 596-602 | pmid=23499356 | doi=10.1016/j.healun.2013.02.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23499356 }} </ref> Therefore supplementing these techniques to annual coronary angiography, especially in the initial years of heart transplantation may aid in identifying high-risk subjects and appropriately risk stratifying them. However, currently studies do not exist to support this strategy.

Stanford classification:
{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Class}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Intimal Thickening}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class 0 (none)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| No intimal thickening
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class I (trivial)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class II (mild)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 mm and >180° circumference or 0.3 to 0.5 mm and 180° circumference
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class III (moderate)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening 0.3 to 0.5 mm and >180° circumference or intimal thickening 0.5 to 1 mm and 180° circumference

|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Class IV (severe)'''
| style="width: 250px; background: #DCDCDC; padding: 5px;"| Intimal thickening >0.5 mm and >180° circumference or intimal thickening >1 mm
|}

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy intravascular ultrasound

2014-08-12T18:39:08Z

Raviteja Reddy Guddeti: /* Overview */

Cardiac allograft vasculopathy intravascular ultrasound

2014-08-12T18:33:56Z

Raviteja Reddy Guddeti: /* Overview */

Cardiac allograft vasculopathy intravascular ultrasound

2014-08-12T18:27:27Z

Raviteja Reddy Guddeti: Created page with "__NOTOC__ {{Cardiac allograft vasculopathy}} {{CMG}}; {{AE}} {{AN}}; {{RT}} ==Overview== ==Intravascular Ultrasound== ==References== {{reflist|2}} {{WH}} {{WS}} Category..."

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==

==Intravascular Ultrasound==

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy coronary angiography

2014-08-04T21:50:10Z

Raviteja Reddy Guddeti: /* Limitations */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Early diagnosis of cardiac allograft vasculopathy (CAV) is of utmost importance as it allows alterations to optimal immunosuppression and risk factor modification prolonging graft survival and reducing morbidity and mortality. In most transplant centers [[coronary angiography]] is currently used to screen and diagnose transplant associated [[coronary artery disease]].

==Coronary Angiography==
Previously, the diagnosis of CAV was made pathologically. However, with the advent of calcineurin-based immunosuppression post-cardiac transplant survival improved significantly and angiographic diagnosis became a standard. Currently, the International Society for Heart and Lung Transplantation (ISHLT) recommends annual invasive coronary angiography as the standard imaging technique to screen for CAV.<ref name="pmid20643330">{{cite journal| author=Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S et al.| title=The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 8 | pages= 914-56 | pmid=20643330 | doi=10.1016/j.healun.2010.05.034 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20643330 }} </ref> Angiographic evidence of coronary artery disease is very common after [[heart transplantation]]. In a multiinstitutional study by Constanzo et al it was demonstrated that by the end of 5 years after transplantation 42% of heart transplant subjects had angiographic evidence of graft coronary artery disease.<ref name="pmid9730422">{{cite journal| author=Costanzo MR, Naftel DC, Pritzker MR, Heilman JK, Boehmer JP, Brozena SC et al.| title=Heart transplant coronary artery disease detected by coronary angiography: a multiinstitutional study of preoperative donor and recipient risk factors. Cardiac Transplant Research Database. | journal=J Heart Lung Transplant | year= 1998 | volume= 17 | issue= 8 | pages= 744-53 | pmid=9730422 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9730422 }} </ref>

===Coronary Artery Morphology in CAV===
In contrast to native coronary artery disease where there is focal, eccentric narrowing of the coronary vessels, CAV involves a more diffuse process that manifests initially as intimal thickening followed later by concentric, longitudinal lesions.<ref name="pmid2795279">{{cite journal| author=Johnson DE, Gao SZ, Schroeder JS, DeCampli WM, Billingham ME| title=The spectrum of coronary artery pathologic findings in human cardiac allografts. | journal=J Heart Transplant | year= 1989 | volume= 8 | issue= 5 | pages= 349-59 | pmid=2795279 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2795279 }} </ref><ref name="pmid2669276">{{cite journal| author=Billingham ME| title=Graft coronary disease: the lesions and the patients. | journal=Transplant Proc | year= 1989 | volume= 21 | issue= 4 | pages= 3665-6 | pmid=2669276 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2669276 }} </ref><ref name="pmid7798497">{{cite journal| author=Rickenbacher PR, Pinto FJ, Chenzbraun A, Botas J, Lewis NP, Alderman EL et al.| title=Incidence and severity of transplant coronary artery disease early and up to 15 years after transplantation as detected by intravascular ultrasound. | journal=J Am Coll Cardiol | year= 1995 | volume= 25 | issue= 1 | pages= 171-7 | pmid=7798497 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7798497 }} </ref><ref name="pmid16143236">{{cite journal| author=Haddad M, Pflugfelder PW, Guiraudon C, Novick RJ, McKenzie FN, Menkis A et al.| title=Angiographic, pathologic, and clinical relationships in coronary artery disease in cardiac allografts. | journal=J Heart Lung Transplant | year= 2005 | volume= 24 | issue= 9 | pages= 1218-25 | pmid=16143236 | doi=10.1016/j.healun.2004.08.016 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16143236 }} </ref> The earliest description of coronary artery morphology in CAV was given my Gao et al.<ref name="pmid3292629">{{cite journal| author=Gao SZ, Alderman EL, Schroeder JS, Silverman JF, Hunt SA| title=Accelerated coronary vascular disease in the heart transplant patient: coronary arteriographic findings. | journal=J Am Coll Cardiol | year= 1988 | volume= 12 | issue= 2 | pages= 334-40 | pmid=3292629 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3292629 }} </ref> According to the classification by Gao et al coronary lesions were classified as Type A, discrete stenosis, tubular stenosis, multiple stenoses in the proximal, middle and distal segments of coronary arteries; Type B, diffuse concentric narrowing of the coronary arteries with onset in the mid to distal segments; and Type C, diseased vessels, diffusely irregular with loss of small branches. However the nomenclature failed to provide prognostic significance of lesion classification. In 2010 the International Society for Heart and Lung Transplantation (ISHLT) proposed a standard nomenclature for CAV by integrating coronary angiographic findings with graft function and hemodynamics.

The ISHLT recommended standard nomenclature for CAV:<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>

{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Classification}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Severity}}
! style="width: 250px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Definition¶}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV0'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Not significant
| style="width: 250px; background: #F5F5F5; padding: 5px;"| No detectable angiographic lesions
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV1'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Mild
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or primary vessel with maximum lesion of 70%, or any branch stenosis of 70% (including diffuse narrowing) without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV2'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Moderate
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%; a single primary vessel 70%, or isolated branch stenosis of 70% in branches of 2 systems, without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV3'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Severe
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or 2 or more primary vessels 70% stenosis, or isolated branch stenosis 70% in all 3 systems; or ISHLT CAV1 or CAV2 with allograft dysfunction (defined as left ventricular ejection fraction >45%, usually in the presence of regional wall motion abnormalities) or evidence of significant restrictive physiology
|}

¶ A “primary vessel” denotes the proximal and middle 33% of the left anterior descending artery, the left circumflex, the ramus, and the dominant or codominant right coronary artery with the posterior descending and posterolateral branches. A “secondary branch vessel” includes the distal 33% of the primary vessels or any segment within a large septal perforator, diagonals, and obtuse marginal branches or any portion of a nondominant right coronary artery. Restrictive cardiac allograft physiology is defined as symptomatic heart failure with echocardiographic E to A velocity ratio of 2 (1.5 in children), shortened isovolumetric relaxation time (60 ms), shortened deceleration time (150 ms), or restrictive hemodynamic values (right atrial pressure 12 mm Hg, pulmonary capillary wedge pressure 25 mm Hg, cardiac index 2 l/min/m2). Adapted from the 2010 ISHLT consensus statement for recommended nomenclature of CAV

===Advantages===
# Wide acceptability<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>
# Reduced healthcare cost compared with other novel intracoronary imaging techniques
# Ease of performance

===Limitations===
# Lower [[sensitivity]] compared with histopathological studies, [[intravascular ultrasound]] ([[IVUS]]) and [[optical coherence tomography]] ([[OCT]]), especially in detecting early-stage CAV<ref name="pmid11243599">{{cite journal| author=Nissen S| title=Coronary angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 2001 | volume= 87 | issue= 4A | pages= 15A-20A | pmid=11243599 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11243599 }} </ref><ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref><ref name="pmid10363681">{{cite journal| author=Spes CH, Klauss V, Rieber J, Schnaack SD, Tammen AR, Uberfuhr P et al.| title=Functional and morphological findings in heart transplant recipients with a normal coronary angiogram: an analysis by dobutamine stress echocardiography, intracoronary Doppler and intravascular ultrasound. | journal=J Heart Lung Transplant | year= 1999 | volume= 18 | issue= 5 | pages= 391-8 | pmid=10363681 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10363681 }} </ref><ref name="pmid15862431">{{cite journal| author=Tuzcu EM, Kapadia SR, Sachar R, Ziada KM, Crowe TD, Feng J et al.| title=Intravascular ultrasound evidence of angiographically silent progression in coronary atherosclerosis predicts long-term morbidity and mortality after cardiac transplantation. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 9 | pages= 1538-42 | pmid=15862431 | doi=10.1016/j.jacc.2004.12.076 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15862431 }} </ref> Coronary angiography assesses only the arterial lumen but not the wall per se. Studies have demonstrated that early after heart transplantation disease pathology is confined to coronary arterial wall with minimal narrowing of the lumen. Therefore luminal assessment alone may lead to underestimation of the extent of disease pathology in early-CAV.<ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref> In a 2006 study by Stork et al in 54 heart transplant recipients it was demonstrated that the positive predictive value of coronary angiography in detecting CAV was only 44% compared with IVUS.<ref name="pmid16962473">{{cite journal| author=Störk S, Behr TM, Birk M, Uberfuhr P, Klauss V, Spes CH et al.| title=Assessment of cardiac allograft vasculopathy late after heart transplantation: when is coronary angiography necessary? | journal=J Heart Lung Transplant | year= 2006 | volume= 25 | issue= 9 | pages= 1103-8 | pmid=16962473 | doi=10.1016/j.healun.2006.05.009 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16962473 }} </ref>Similarly, using histologic correlations Johnson et al reported that lesions less than 25% stenosis were underestimated by coronary angiography.<ref name="pmid1991903">{{cite journal| author=Johnson DE, Alderman EL, Schroeder JS, Gao SZ, Hunt S, DeCampli WM et al.| title=Transplant coronary artery disease: histopathologic correlations with angiographic morphology. | journal=J Am Coll Cardiol | year= 1991 | volume= 17 | issue= 2 | pages= 449-57 | pmid=1991903 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1991903 }} </ref> Also, positive remodeling that occurs early in the course of atherosclerosis and that is associated with plaque vulnerability is not detected by angiography.<ref name="pmid3574413">{{cite journal| author=Glagov S, Weisenberg E, Zarins CK, Stankunavicius R, Kolettis GJ| title=Compensatory enlargement of human atherosclerotic coronary arteries. | journal=N Engl J Med | year= 1987 | volume= 316 | issue= 22 | pages= 1371-5 | pmid=3574413 | doi=10.1056/NEJM198705283162204 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3574413 }} </ref><ref name="pmid18577556">{{cite journal| author=Raffel OC, Merchant FM, Tearney GJ, Chia S, Gauthier DD, Pomerantsev E et al.| title=In vivo association between positive coronary artery remodelling and coronary plaque characteristics assessed by intravascular optical coherence tomography. | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 14 | pages= 1721-8 | pmid=18577556 | doi=10.1093/eurheartj/ehn286 | pmc=PMC2730912 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18577556 }} </ref><ref name="pmid16790471">{{cite journal| author=Li H, Tanaka K, Oeser B, Kobashigawa JA, Tobis JM| title=Vascular remodelling after cardiac transplantation: a 3-year serial intravascular ultrasound study. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 14 | pages= 1671-7 | pmid=16790471 | doi=10.1093/eurheartj/ehl097 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16790471 }} </ref>
# Risk of [[contrast-induced nephropathy|contrast nephropathy]] in [[heart transplant]] subjects in whom [[chronic renal failure]] is a usual comorbidity<ref name="pmid10770975">{{cite journal| author=Lindelöw B, Bergh CH, Herlitz H, Waagstein F| title=Predictors and evolution of renal function during 9 years following heart transplantation. | journal=J Am Soc Nephrol | year= 2000 | volume= 11 | issue= 5 | pages= 951-7 | pmid=10770975 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10770975 }} </ref>

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy coronary angiography

2014-08-04T21:47:01Z

Raviteja Reddy Guddeti: /* Limitations */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Early diagnosis of cardiac allograft vasculopathy (CAV) is of utmost importance as it allows alterations to optimal immunosuppression and risk factor modification prolonging graft survival and reducing morbidity and mortality. In most transplant centers [[coronary angiography]] is currently used to screen and diagnose transplant associated [[coronary artery disease]].

==Coronary Angiography==
Previously, the diagnosis of CAV was made pathologically. However, with the advent of calcineurin-based immunosuppression post-cardiac transplant survival improved significantly and angiographic diagnosis became a standard. Currently, the International Society for Heart and Lung Transplantation (ISHLT) recommends annual invasive coronary angiography as the standard imaging technique to screen for CAV.<ref name="pmid20643330">{{cite journal| author=Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S et al.| title=The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 8 | pages= 914-56 | pmid=20643330 | doi=10.1016/j.healun.2010.05.034 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20643330 }} </ref> Angiographic evidence of coronary artery disease is very common after [[heart transplantation]]. In a multiinstitutional study by Constanzo et al it was demonstrated that by the end of 5 years after transplantation 42% of heart transplant subjects had angiographic evidence of graft coronary artery disease.<ref name="pmid9730422">{{cite journal| author=Costanzo MR, Naftel DC, Pritzker MR, Heilman JK, Boehmer JP, Brozena SC et al.| title=Heart transplant coronary artery disease detected by coronary angiography: a multiinstitutional study of preoperative donor and recipient risk factors. Cardiac Transplant Research Database. | journal=J Heart Lung Transplant | year= 1998 | volume= 17 | issue= 8 | pages= 744-53 | pmid=9730422 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9730422 }} </ref>

===Coronary Artery Morphology in CAV===
In contrast to native coronary artery disease where there is focal, eccentric narrowing of the coronary vessels, CAV involves a more diffuse process that manifests initially as intimal thickening followed later by concentric, longitudinal lesions.<ref name="pmid2795279">{{cite journal| author=Johnson DE, Gao SZ, Schroeder JS, DeCampli WM, Billingham ME| title=The spectrum of coronary artery pathologic findings in human cardiac allografts. | journal=J Heart Transplant | year= 1989 | volume= 8 | issue= 5 | pages= 349-59 | pmid=2795279 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2795279 }} </ref><ref name="pmid2669276">{{cite journal| author=Billingham ME| title=Graft coronary disease: the lesions and the patients. | journal=Transplant Proc | year= 1989 | volume= 21 | issue= 4 | pages= 3665-6 | pmid=2669276 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2669276 }} </ref><ref name="pmid7798497">{{cite journal| author=Rickenbacher PR, Pinto FJ, Chenzbraun A, Botas J, Lewis NP, Alderman EL et al.| title=Incidence and severity of transplant coronary artery disease early and up to 15 years after transplantation as detected by intravascular ultrasound. | journal=J Am Coll Cardiol | year= 1995 | volume= 25 | issue= 1 | pages= 171-7 | pmid=7798497 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7798497 }} </ref><ref name="pmid16143236">{{cite journal| author=Haddad M, Pflugfelder PW, Guiraudon C, Novick RJ, McKenzie FN, Menkis A et al.| title=Angiographic, pathologic, and clinical relationships in coronary artery disease in cardiac allografts. | journal=J Heart Lung Transplant | year= 2005 | volume= 24 | issue= 9 | pages= 1218-25 | pmid=16143236 | doi=10.1016/j.healun.2004.08.016 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16143236 }} </ref> The earliest description of coronary artery morphology in CAV was given my Gao et al.<ref name="pmid3292629">{{cite journal| author=Gao SZ, Alderman EL, Schroeder JS, Silverman JF, Hunt SA| title=Accelerated coronary vascular disease in the heart transplant patient: coronary arteriographic findings. | journal=J Am Coll Cardiol | year= 1988 | volume= 12 | issue= 2 | pages= 334-40 | pmid=3292629 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3292629 }} </ref> According to the classification by Gao et al coronary lesions were classified as Type A, discrete stenosis, tubular stenosis, multiple stenoses in the proximal, middle and distal segments of coronary arteries; Type B, diffuse concentric narrowing of the coronary arteries with onset in the mid to distal segments; and Type C, diseased vessels, diffusely irregular with loss of small branches. However the nomenclature failed to provide prognostic significance of lesion classification. In 2010 the International Society for Heart and Lung Transplantation (ISHLT) proposed a standard nomenclature for CAV by integrating coronary angiographic findings with graft function and hemodynamics.

The ISHLT recommended standard nomenclature for CAV:<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>

{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Classification}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Severity}}
! style="width: 250px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Definition¶}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV0'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Not significant
| style="width: 250px; background: #F5F5F5; padding: 5px;"| No detectable angiographic lesions
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV1'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Mild
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or primary vessel with maximum lesion of 70%, or any branch stenosis of 70% (including diffuse narrowing) without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV2'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Moderate
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%; a single primary vessel 70%, or isolated branch stenosis of 70% in branches of 2 systems, without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV3'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Severe
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or 2 or more primary vessels 70% stenosis, or isolated branch stenosis 70% in all 3 systems; or ISHLT CAV1 or CAV2 with allograft dysfunction (defined as left ventricular ejection fraction >45%, usually in the presence of regional wall motion abnormalities) or evidence of significant restrictive physiology
|}

¶ A “primary vessel” denotes the proximal and middle 33% of the left anterior descending artery, the left circumflex, the ramus, and the dominant or codominant right coronary artery with the posterior descending and posterolateral branches. A “secondary branch vessel” includes the distal 33% of the primary vessels or any segment within a large septal perforator, diagonals, and obtuse marginal branches or any portion of a nondominant right coronary artery. Restrictive cardiac allograft physiology is defined as symptomatic heart failure with echocardiographic E to A velocity ratio of 2 (1.5 in children), shortened isovolumetric relaxation time (60 ms), shortened deceleration time (150 ms), or restrictive hemodynamic values (right atrial pressure 12 mm Hg, pulmonary capillary wedge pressure 25 mm Hg, cardiac index 2 l/min/m2). Adapted from the 2010 ISHLT consensus statement for recommended nomenclature of CAV

===Advantages===
# Wide acceptability<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>
# Reduced healthcare cost compared with other novel intracoronary imaging techniques
# Ease of performance

===Limitations===
# Lower [[sensitivity]] compared with histopathological studies, [[intravascular ultrasound]] ([[IVUS]]) and [[optical coherence tomography]] ([[OCT]]), especially in detecting early-stage CAV<ref name="pmid11243599">{{cite journal| author=Nissen S| title=Coronary angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 2001 | volume= 87 | issue= 4A | pages= 15A-20A | pmid=11243599 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11243599 }} </ref><ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref><ref name="pmid10363681">{{cite journal| author=Spes CH, Klauss V, Rieber J, Schnaack SD, Tammen AR, Uberfuhr P et al.| title=Functional and morphological findings in heart transplant recipients with a normal coronary angiogram: an analysis by dobutamine stress echocardiography, intracoronary Doppler and intravascular ultrasound. | journal=J Heart Lung Transplant | year= 1999 | volume= 18 | issue= 5 | pages= 391-8 | pmid=10363681 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10363681 }} </ref><ref name="pmid15862431">{{cite journal| author=Tuzcu EM, Kapadia SR, Sachar R, Ziada KM, Crowe TD, Feng J et al.| title=Intravascular ultrasound evidence of angiographically silent progression in coronary atherosclerosis predicts long-term morbidity and mortality after cardiac transplantation. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 9 | pages= 1538-42 | pmid=15862431 | doi=10.1016/j.jacc.2004.12.076 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15862431 }} </ref> Coronary angiography assesses only the arterial lumen but not the wall per se. Studies have demonstrated that early after heart transplantation disease pathology is confined to coronary arterial wall with minimal narrowing of the lumen. Therefore luminal assessment alone may lead to underestimation of the extent of disease pathology in early-CAV.<ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref> In a 2006 study by Stork et al in 54 heart transplant recipients it was demonstrated that the positive predictive value of coronary angiography in detecting CAV was only 44% compared with IVUS.<ref name="pmid16962473">{{cite journal| author=Störk S, Behr TM, Birk M, Uberfuhr P, Klauss V, Spes CH et al.| title=Assessment of cardiac allograft vasculopathy late after heart transplantation: when is coronary angiography necessary? | journal=J Heart Lung Transplant | year= 2006 | volume= 25 | issue= 9 | pages= 1103-8 | pmid=16962473 | doi=10.1016/j.healun.2006.05.009 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16962473 }} </ref>Similarly, using histologic correlations Johnson et al reported that lesions less than 25% stenosis were underestimated by coronary angiography.<ref name="pmid1991903">{{cite journal| author=Johnson DE, Alderman EL, Schroeder JS, Gao SZ, Hunt S, DeCampli WM et al.| title=Transplant coronary artery disease: histopathologic correlations with angiographic morphology. | journal=J Am Coll Cardiol | year= 1991 | volume= 17 | issue= 2 | pages= 449-57 | pmid=1991903 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1991903 }} </ref> Also, positive remodeling that occurs early in the course of atherosclerosis and that is associated with plaque vulnerability is not detected by angiography.<ref name="pmid3574413">{{cite journal| author=Glagov S, Weisenberg E, Zarins CK, Stankunavicius R, Kolettis GJ| title=Compensatory enlargement of human atherosclerotic coronary arteries. | journal=N Engl J Med | year= 1987 | volume= 316 | issue= 22 | pages= 1371-5 | pmid=3574413 | doi=10.1056/NEJM198705283162204 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3574413 }} </ref><ref name="pmid18577556">{{cite journal| author=Raffel OC, Merchant FM, Tearney GJ, Chia S, Gauthier DD, Pomerantsev E et al.| title=In vivo association between positive coronary artery remodelling and coronary plaque characteristics assessed by intravascular optical coherence tomography. | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 14 | pages= 1721-8 | pmid=18577556 | doi=10.1093/eurheartj/ehn286 | pmc=PMC2730912 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18577556 }} </ref>
# Risk of [[contrast-induced nephropathy|contrast nephropathy]] in [[heart transplant]] subjects in whom [[chronic renal failure]] is a usual comorbidity<ref name="pmid10770975">{{cite journal| author=Lindelöw B, Bergh CH, Herlitz H, Waagstein F| title=Predictors and evolution of renal function during 9 years following heart transplantation. | journal=J Am Soc Nephrol | year= 2000 | volume= 11 | issue= 5 | pages= 951-7 | pmid=10770975 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10770975 }} </ref>

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy coronary angiography

2014-08-04T21:23:15Z

Raviteja Reddy Guddeti: /* Limitations */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Early diagnosis of cardiac allograft vasculopathy (CAV) is of utmost importance as it allows alterations to optimal immunosuppression and risk factor modification prolonging graft survival and reducing morbidity and mortality. In most transplant centers [[coronary angiography]] is currently used to screen and diagnose transplant associated [[coronary artery disease]].

==Coronary Angiography==
Previously, the diagnosis of CAV was made pathologically. However, with the advent of calcineurin-based immunosuppression post-cardiac transplant survival improved significantly and angiographic diagnosis became a standard. Currently, the International Society for Heart and Lung Transplantation (ISHLT) recommends annual invasive coronary angiography as the standard imaging technique to screen for CAV.<ref name="pmid20643330">{{cite journal| author=Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S et al.| title=The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 8 | pages= 914-56 | pmid=20643330 | doi=10.1016/j.healun.2010.05.034 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20643330 }} </ref> Angiographic evidence of coronary artery disease is very common after [[heart transplantation]]. In a multiinstitutional study by Constanzo et al it was demonstrated that by the end of 5 years after transplantation 42% of heart transplant subjects had angiographic evidence of graft coronary artery disease.<ref name="pmid9730422">{{cite journal| author=Costanzo MR, Naftel DC, Pritzker MR, Heilman JK, Boehmer JP, Brozena SC et al.| title=Heart transplant coronary artery disease detected by coronary angiography: a multiinstitutional study of preoperative donor and recipient risk factors. Cardiac Transplant Research Database. | journal=J Heart Lung Transplant | year= 1998 | volume= 17 | issue= 8 | pages= 744-53 | pmid=9730422 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9730422 }} </ref>

===Coronary Artery Morphology in CAV===
In contrast to native coronary artery disease where there is focal, eccentric narrowing of the coronary vessels, CAV involves a more diffuse process that manifests initially as intimal thickening followed later by concentric, longitudinal lesions.<ref name="pmid2795279">{{cite journal| author=Johnson DE, Gao SZ, Schroeder JS, DeCampli WM, Billingham ME| title=The spectrum of coronary artery pathologic findings in human cardiac allografts. | journal=J Heart Transplant | year= 1989 | volume= 8 | issue= 5 | pages= 349-59 | pmid=2795279 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2795279 }} </ref><ref name="pmid2669276">{{cite journal| author=Billingham ME| title=Graft coronary disease: the lesions and the patients. | journal=Transplant Proc | year= 1989 | volume= 21 | issue= 4 | pages= 3665-6 | pmid=2669276 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2669276 }} </ref><ref name="pmid7798497">{{cite journal| author=Rickenbacher PR, Pinto FJ, Chenzbraun A, Botas J, Lewis NP, Alderman EL et al.| title=Incidence and severity of transplant coronary artery disease early and up to 15 years after transplantation as detected by intravascular ultrasound. | journal=J Am Coll Cardiol | year= 1995 | volume= 25 | issue= 1 | pages= 171-7 | pmid=7798497 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7798497 }} </ref><ref name="pmid16143236">{{cite journal| author=Haddad M, Pflugfelder PW, Guiraudon C, Novick RJ, McKenzie FN, Menkis A et al.| title=Angiographic, pathologic, and clinical relationships in coronary artery disease in cardiac allografts. | journal=J Heart Lung Transplant | year= 2005 | volume= 24 | issue= 9 | pages= 1218-25 | pmid=16143236 | doi=10.1016/j.healun.2004.08.016 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16143236 }} </ref> The earliest description of coronary artery morphology in CAV was given my Gao et al.<ref name="pmid3292629">{{cite journal| author=Gao SZ, Alderman EL, Schroeder JS, Silverman JF, Hunt SA| title=Accelerated coronary vascular disease in the heart transplant patient: coronary arteriographic findings. | journal=J Am Coll Cardiol | year= 1988 | volume= 12 | issue= 2 | pages= 334-40 | pmid=3292629 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3292629 }} </ref> According to the classification by Gao et al coronary lesions were classified as Type A, discrete stenosis, tubular stenosis, multiple stenoses in the proximal, middle and distal segments of coronary arteries; Type B, diffuse concentric narrowing of the coronary arteries with onset in the mid to distal segments; and Type C, diseased vessels, diffusely irregular with loss of small branches. However the nomenclature failed to provide prognostic significance of lesion classification. In 2010 the International Society for Heart and Lung Transplantation (ISHLT) proposed a standard nomenclature for CAV by integrating coronary angiographic findings with graft function and hemodynamics.

The ISHLT recommended standard nomenclature for CAV:<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>

{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Classification}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Severity}}
! style="width: 250px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Definition¶}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV0'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Not significant
| style="width: 250px; background: #F5F5F5; padding: 5px;"| No detectable angiographic lesions
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV1'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Mild
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or primary vessel with maximum lesion of 70%, or any branch stenosis of 70% (including diffuse narrowing) without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV2'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Moderate
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%; a single primary vessel 70%, or isolated branch stenosis of 70% in branches of 2 systems, without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV3'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Severe
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or 2 or more primary vessels 70% stenosis, or isolated branch stenosis 70% in all 3 systems; or ISHLT CAV1 or CAV2 with allograft dysfunction (defined as left ventricular ejection fraction >45%, usually in the presence of regional wall motion abnormalities) or evidence of significant restrictive physiology
|}

¶ A “primary vessel” denotes the proximal and middle 33% of the left anterior descending artery, the left circumflex, the ramus, and the dominant or codominant right coronary artery with the posterior descending and posterolateral branches. A “secondary branch vessel” includes the distal 33% of the primary vessels or any segment within a large septal perforator, diagonals, and obtuse marginal branches or any portion of a nondominant right coronary artery. Restrictive cardiac allograft physiology is defined as symptomatic heart failure with echocardiographic E to A velocity ratio of 2 (1.5 in children), shortened isovolumetric relaxation time (60 ms), shortened deceleration time (150 ms), or restrictive hemodynamic values (right atrial pressure 12 mm Hg, pulmonary capillary wedge pressure 25 mm Hg, cardiac index 2 l/min/m2). Adapted from the 2010 ISHLT consensus statement for recommended nomenclature of CAV

===Advantages===
# Wide acceptability<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>
# Reduced healthcare cost compared with other novel intracoronary imaging techniques
# Ease of performance

===Limitations===
# Lower [[sensitivity]] compared with histopathological studies, [[intravascular ultrasound]] ([[IVUS]]) and [[optical coherence tomography]] ([[OCT]]), especially in detecting early-stage CAV<ref name="pmid11243599">{{cite journal| author=Nissen S| title=Coronary angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 2001 | volume= 87 | issue= 4A | pages= 15A-20A | pmid=11243599 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11243599 }} </ref><ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref><ref name="pmid10363681">{{cite journal| author=Spes CH, Klauss V, Rieber J, Schnaack SD, Tammen AR, Uberfuhr P et al.| title=Functional and morphological findings in heart transplant recipients with a normal coronary angiogram: an analysis by dobutamine stress echocardiography, intracoronary Doppler and intravascular ultrasound. | journal=J Heart Lung Transplant | year= 1999 | volume= 18 | issue= 5 | pages= 391-8 | pmid=10363681 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10363681 }} </ref><ref name="pmid15862431">{{cite journal| author=Tuzcu EM, Kapadia SR, Sachar R, Ziada KM, Crowe TD, Feng J et al.| title=Intravascular ultrasound evidence of angiographically silent progression in coronary atherosclerosis predicts long-term morbidity and mortality after cardiac transplantation. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 9 | pages= 1538-42 | pmid=15862431 | doi=10.1016/j.jacc.2004.12.076 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15862431 }} </ref> Coronary angiography assesses only the arterial lumen but not the wall per se. Studies have demonstrated that early after heart transplantation disease pathology is confined to coronary arterial wall with minimal narrowing of the lumen. Therefore luminal assessment alone may lead to underestimation of the extent of disease pathology in early-CAV.<ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref>
# Risk of [[contrast-induced nephropathy|contrast nephropathy]] in [[heart transplant]] subjects in whom [[chronic renal failure]] is a usual comorbidity<ref name="pmid10770975">{{cite journal| author=Lindelöw B, Bergh CH, Herlitz H, Waagstein F| title=Predictors and evolution of renal function during 9 years following heart transplantation. | journal=J Am Soc Nephrol | year= 2000 | volume= 11 | issue= 5 | pages= 951-7 | pmid=10770975 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10770975 }} </ref>

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy coronary angiography

2014-08-04T21:09:32Z

Raviteja Reddy Guddeti: /* Coronary Artery Morphology in CAV */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Early diagnosis of cardiac allograft vasculopathy (CAV) is of utmost importance as it allows alterations to optimal immunosuppression and risk factor modification prolonging graft survival and reducing morbidity and mortality. In most transplant centers [[coronary angiography]] is currently used to screen and diagnose transplant associated [[coronary artery disease]].

==Coronary Angiography==
Previously, the diagnosis of CAV was made pathologically. However, with the advent of calcineurin-based immunosuppression post-cardiac transplant survival improved significantly and angiographic diagnosis became a standard. Currently, the International Society for Heart and Lung Transplantation (ISHLT) recommends annual invasive coronary angiography as the standard imaging technique to screen for CAV.<ref name="pmid20643330">{{cite journal| author=Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S et al.| title=The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 8 | pages= 914-56 | pmid=20643330 | doi=10.1016/j.healun.2010.05.034 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20643330 }} </ref> Angiographic evidence of coronary artery disease is very common after [[heart transplantation]]. In a multiinstitutional study by Constanzo et al it was demonstrated that by the end of 5 years after transplantation 42% of heart transplant subjects had angiographic evidence of graft coronary artery disease.<ref name="pmid9730422">{{cite journal| author=Costanzo MR, Naftel DC, Pritzker MR, Heilman JK, Boehmer JP, Brozena SC et al.| title=Heart transplant coronary artery disease detected by coronary angiography: a multiinstitutional study of preoperative donor and recipient risk factors. Cardiac Transplant Research Database. | journal=J Heart Lung Transplant | year= 1998 | volume= 17 | issue= 8 | pages= 744-53 | pmid=9730422 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9730422 }} </ref>

===Coronary Artery Morphology in CAV===
In contrast to native coronary artery disease where there is focal, eccentric narrowing of the coronary vessels, CAV involves a more diffuse process that manifests initially as intimal thickening followed later by concentric, longitudinal lesions.<ref name="pmid2795279">{{cite journal| author=Johnson DE, Gao SZ, Schroeder JS, DeCampli WM, Billingham ME| title=The spectrum of coronary artery pathologic findings in human cardiac allografts. | journal=J Heart Transplant | year= 1989 | volume= 8 | issue= 5 | pages= 349-59 | pmid=2795279 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2795279 }} </ref><ref name="pmid2669276">{{cite journal| author=Billingham ME| title=Graft coronary disease: the lesions and the patients. | journal=Transplant Proc | year= 1989 | volume= 21 | issue= 4 | pages= 3665-6 | pmid=2669276 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2669276 }} </ref><ref name="pmid7798497">{{cite journal| author=Rickenbacher PR, Pinto FJ, Chenzbraun A, Botas J, Lewis NP, Alderman EL et al.| title=Incidence and severity of transplant coronary artery disease early and up to 15 years after transplantation as detected by intravascular ultrasound. | journal=J Am Coll Cardiol | year= 1995 | volume= 25 | issue= 1 | pages= 171-7 | pmid=7798497 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7798497 }} </ref><ref name="pmid16143236">{{cite journal| author=Haddad M, Pflugfelder PW, Guiraudon C, Novick RJ, McKenzie FN, Menkis A et al.| title=Angiographic, pathologic, and clinical relationships in coronary artery disease in cardiac allografts. | journal=J Heart Lung Transplant | year= 2005 | volume= 24 | issue= 9 | pages= 1218-25 | pmid=16143236 | doi=10.1016/j.healun.2004.08.016 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16143236 }} </ref> The earliest description of coronary artery morphology in CAV was given my Gao et al.<ref name="pmid3292629">{{cite journal| author=Gao SZ, Alderman EL, Schroeder JS, Silverman JF, Hunt SA| title=Accelerated coronary vascular disease in the heart transplant patient: coronary arteriographic findings. | journal=J Am Coll Cardiol | year= 1988 | volume= 12 | issue= 2 | pages= 334-40 | pmid=3292629 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3292629 }} </ref> According to the classification by Gao et al coronary lesions were classified as Type A, discrete stenosis, tubular stenosis, multiple stenoses in the proximal, middle and distal segments of coronary arteries; Type B, diffuse concentric narrowing of the coronary arteries with onset in the mid to distal segments; and Type C, diseased vessels, diffusely irregular with loss of small branches. However the nomenclature failed to provide prognostic significance of lesion classification. In 2010 the International Society for Heart and Lung Transplantation (ISHLT) proposed a standard nomenclature for CAV by integrating coronary angiographic findings with graft function and hemodynamics.

The ISHLT recommended standard nomenclature for CAV:<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>

{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Classification}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Severity}}
! style="width: 250px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Definition¶}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV0'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Not significant
| style="width: 250px; background: #F5F5F5; padding: 5px;"| No detectable angiographic lesions
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV1'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Mild
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or primary vessel with maximum lesion of 70%, or any branch stenosis of 70% (including diffuse narrowing) without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV2'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Moderate
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%; a single primary vessel 70%, or isolated branch stenosis of 70% in branches of 2 systems, without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV3'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Severe
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or 2 or more primary vessels 70% stenosis, or isolated branch stenosis 70% in all 3 systems; or ISHLT CAV1 or CAV2 with allograft dysfunction (defined as left ventricular ejection fraction >45%, usually in the presence of regional wall motion abnormalities) or evidence of significant restrictive physiology
|}

¶ A “primary vessel” denotes the proximal and middle 33% of the left anterior descending artery, the left circumflex, the ramus, and the dominant or codominant right coronary artery with the posterior descending and posterolateral branches. A “secondary branch vessel” includes the distal 33% of the primary vessels or any segment within a large septal perforator, diagonals, and obtuse marginal branches or any portion of a nondominant right coronary artery. Restrictive cardiac allograft physiology is defined as symptomatic heart failure with echocardiographic E to A velocity ratio of 2 (1.5 in children), shortened isovolumetric relaxation time (60 ms), shortened deceleration time (150 ms), or restrictive hemodynamic values (right atrial pressure 12 mm Hg, pulmonary capillary wedge pressure 25 mm Hg, cardiac index 2 l/min/m2). Adapted from the 2010 ISHLT consensus statement for recommended nomenclature of CAV

===Advantages===
# Wide acceptability<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>
# Reduced healthcare cost compared with other novel intracoronary imaging techniques
# Ease of performance

===Limitations===
# Lower [[sensitivity]] compared with histopathological studies, [[intravascular ultrasound]] ([[IVUS]]) and [[optical coherence tomography]] ([[OCT]]), especially in detecting early-stage CAV<ref name="pmid11243599">{{cite journal| author=Nissen S| title=Coronary angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 2001 | volume= 87 | issue= 4A | pages= 15A-20A | pmid=11243599 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11243599 }} </ref><ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref><ref name="pmid10363681">{{cite journal| author=Spes CH, Klauss V, Rieber J, Schnaack SD, Tammen AR, Uberfuhr P et al.| title=Functional and morphological findings in heart transplant recipients with a normal coronary angiogram: an analysis by dobutamine stress echocardiography, intracoronary Doppler and intravascular ultrasound. | journal=J Heart Lung Transplant | year= 1999 | volume= 18 | issue= 5 | pages= 391-8 | pmid=10363681 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10363681 }} </ref><ref name="pmid15862431">{{cite journal| author=Tuzcu EM, Kapadia SR, Sachar R, Ziada KM, Crowe TD, Feng J et al.| title=Intravascular ultrasound evidence of angiographically silent progression in coronary atherosclerosis predicts long-term morbidity and mortality after cardiac transplantation. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 9 | pages= 1538-42 | pmid=15862431 | doi=10.1016/j.jacc.2004.12.076 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15862431 }} </ref> Coronary angiography assesses only the arterial lumen but not the wall per se. Studies have demonstrated that early after heart transplantation disease pathology is confined to coronary arterial wall with minimal narrowing of the lumen.<ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref>
# Risk of [[contrast-induced nephropathy|contrast nephropathy]] in [[heart transplant]] subjects in whom [[chronic renal failure]] is a usual comorbidity<ref name="pmid10770975">{{cite journal| author=Lindelöw B, Bergh CH, Herlitz H, Waagstein F| title=Predictors and evolution of renal function during 9 years following heart transplantation. | journal=J Am Soc Nephrol | year= 2000 | volume= 11 | issue= 5 | pages= 951-7 | pmid=10770975 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10770975 }} </ref>

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy coronary angiography

2014-08-04T21:04:40Z

Raviteja Reddy Guddeti: /* Coronary Artery Morphology in CAV */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Early diagnosis of cardiac allograft vasculopathy (CAV) is of utmost importance as it allows alterations to optimal immunosuppression and risk factor modification prolonging graft survival and reducing morbidity and mortality. In most transplant centers [[coronary angiography]] is currently used to screen and diagnose transplant associated [[coronary artery disease]].

==Coronary Angiography==
Previously, the diagnosis of CAV was made pathologically. However, with the advent of calcineurin-based immunosuppression post-cardiac transplant survival improved significantly and angiographic diagnosis became a standard. Currently, the International Society for Heart and Lung Transplantation (ISHLT) recommends annual invasive coronary angiography as the standard imaging technique to screen for CAV.<ref name="pmid20643330">{{cite journal| author=Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S et al.| title=The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 8 | pages= 914-56 | pmid=20643330 | doi=10.1016/j.healun.2010.05.034 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20643330 }} </ref> Angiographic evidence of coronary artery disease is very common after [[heart transplantation]]. In a multiinstitutional study by Constanzo et al it was demonstrated that by the end of 5 years after transplantation 42% of heart transplant subjects had angiographic evidence of graft coronary artery disease.<ref name="pmid9730422">{{cite journal| author=Costanzo MR, Naftel DC, Pritzker MR, Heilman JK, Boehmer JP, Brozena SC et al.| title=Heart transplant coronary artery disease detected by coronary angiography: a multiinstitutional study of preoperative donor and recipient risk factors. Cardiac Transplant Research Database. | journal=J Heart Lung Transplant | year= 1998 | volume= 17 | issue= 8 | pages= 744-53 | pmid=9730422 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9730422 }} </ref>

===Coronary Artery Morphology in CAV===
In contrast to native coronary artery disease where there is focal, eccentric narrowing of the coronary vessels, CAV involves a more diffuse process that manifests initially as intimal thickening followed by concentric, longitudinal lesions.<ref name="pmid2795279">{{cite journal| author=Johnson DE, Gao SZ, Schroeder JS, DeCampli WM, Billingham ME| title=The spectrum of coronary artery pathologic findings in human cardiac allografts. | journal=J Heart Transplant | year= 1989 | volume= 8 | issue= 5 | pages= 349-59 | pmid=2795279 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2795279 }} </ref><ref name="pmid2669276">{{cite journal| author=Billingham ME| title=Graft coronary disease: the lesions and the patients. | journal=Transplant Proc | year= 1989 | volume= 21 | issue= 4 | pages= 3665-6 | pmid=2669276 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2669276 }} </ref><ref name="pmid7798497">{{cite journal| author=Rickenbacher PR, Pinto FJ, Chenzbraun A, Botas J, Lewis NP, Alderman EL et al.| title=Incidence and severity of transplant coronary artery disease early and up to 15 years after transplantation as detected by intravascular ultrasound. | journal=J Am Coll Cardiol | year= 1995 | volume= 25 | issue= 1 | pages= 171-7 | pmid=7798497 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7798497 }} </ref><ref name="pmid16143236">{{cite journal| author=Haddad M, Pflugfelder PW, Guiraudon C, Novick RJ, McKenzie FN, Menkis A et al.| title=Angiographic, pathologic, and clinical relationships in coronary artery disease in cardiac allografts. | journal=J Heart Lung Transplant | year= 2005 | volume= 24 | issue= 9 | pages= 1218-25 | pmid=16143236 | doi=10.1016/j.healun.2004.08.016 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16143236 }} </ref> The earliest description of coronary artery morphology in CAV was given my Gao et al.<ref name="pmid3292629">{{cite journal| author=Gao SZ, Alderman EL, Schroeder JS, Silverman JF, Hunt SA| title=Accelerated coronary vascular disease in the heart transplant patient: coronary arteriographic findings. | journal=J Am Coll Cardiol | year= 1988 | volume= 12 | issue= 2 | pages= 334-40 | pmid=3292629 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3292629 }} </ref> According to the classification by Gao et al coronary lesions were classified as Type A, discrete stenosis, tubular stenosis, multiple stenoses in the proximal, middle and distal segments of coronary arteries; Type B, diffuse concentric narrowing of the coronary arteries with onset in the mid to distal segments; and Type C, diseased vessels, diffusely irregular with loss of small branches. However the nomenclature failed to provide prognostic significance of lesion classification. In 2010 the International Society for Heart and Lung Transplantation (ISHLT) proposed a standard nomenclature for CAV by integrating coronary angiographic findings with graft function and hemodynamics.

The ISHLT recommended standard nomenclature for CAV:<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>

{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Classification}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Severity}}
! style="width: 250px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Definition¶}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV0'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Not significant
| style="width: 250px; background: #F5F5F5; padding: 5px;"| No detectable angiographic lesions
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV1'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Mild
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or primary vessel with maximum lesion of 70%, or any branch stenosis of 70% (including diffuse narrowing) without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV2'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Moderate
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%; a single primary vessel 70%, or isolated branch stenosis of 70% in branches of 2 systems, without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV3'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Severe
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or 2 or more primary vessels 70% stenosis, or isolated branch stenosis 70% in all 3 systems; or ISHLT CAV1 or CAV2 with allograft dysfunction (defined as left ventricular ejection fraction >45%, usually in the presence of regional wall motion abnormalities) or evidence of significant restrictive physiology
|}

¶ A “primary vessel” denotes the proximal and middle 33% of the left anterior descending artery, the left circumflex, the ramus, and the dominant or codominant right coronary artery with the posterior descending and posterolateral branches. A “secondary branch vessel” includes the distal 33% of the primary vessels or any segment within a large septal perforator, diagonals, and obtuse marginal branches or any portion of a nondominant right coronary artery. Restrictive cardiac allograft physiology is defined as symptomatic heart failure with echocardiographic E to A velocity ratio of 2 (1.5 in children), shortened isovolumetric relaxation time (60 ms), shortened deceleration time (150 ms), or restrictive hemodynamic values (right atrial pressure 12 mm Hg, pulmonary capillary wedge pressure 25 mm Hg, cardiac index 2 l/min/m2). Adapted from the 2010 ISHLT consensus statement for recommended nomenclature of CAV

===Advantages===
# Wide acceptability<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>
# Reduced healthcare cost compared with other novel intracoronary imaging techniques
# Ease of performance

===Limitations===
# Lower [[sensitivity]] compared with histopathological studies, [[intravascular ultrasound]] ([[IVUS]]) and [[optical coherence tomography]] ([[OCT]]), especially in detecting early-stage CAV<ref name="pmid11243599">{{cite journal| author=Nissen S| title=Coronary angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 2001 | volume= 87 | issue= 4A | pages= 15A-20A | pmid=11243599 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11243599 }} </ref><ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref><ref name="pmid10363681">{{cite journal| author=Spes CH, Klauss V, Rieber J, Schnaack SD, Tammen AR, Uberfuhr P et al.| title=Functional and morphological findings in heart transplant recipients with a normal coronary angiogram: an analysis by dobutamine stress echocardiography, intracoronary Doppler and intravascular ultrasound. | journal=J Heart Lung Transplant | year= 1999 | volume= 18 | issue= 5 | pages= 391-8 | pmid=10363681 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10363681 }} </ref><ref name="pmid15862431">{{cite journal| author=Tuzcu EM, Kapadia SR, Sachar R, Ziada KM, Crowe TD, Feng J et al.| title=Intravascular ultrasound evidence of angiographically silent progression in coronary atherosclerosis predicts long-term morbidity and mortality after cardiac transplantation. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 9 | pages= 1538-42 | pmid=15862431 | doi=10.1016/j.jacc.2004.12.076 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15862431 }} </ref> Coronary angiography assesses only the arterial lumen but not the wall per se. Studies have demonstrated that early after heart transplantation disease pathology is confined to coronary arterial wall with minimal narrowing of the lumen.<ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref>
# Risk of [[contrast-induced nephropathy|contrast nephropathy]] in [[heart transplant]] subjects in whom [[chronic renal failure]] is a usual comorbidity<ref name="pmid10770975">{{cite journal| author=Lindelöw B, Bergh CH, Herlitz H, Waagstein F| title=Predictors and evolution of renal function during 9 years following heart transplantation. | journal=J Am Soc Nephrol | year= 2000 | volume= 11 | issue= 5 | pages= 951-7 | pmid=10770975 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10770975 }} </ref>

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy coronary angiography

2014-08-04T21:03:15Z

Raviteja Reddy Guddeti: /* Coronary Artery Morphology in CAV */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Early diagnosis of cardiac allograft vasculopathy (CAV) is of utmost importance as it allows alterations to optimal immunosuppression and risk factor modification prolonging graft survival and reducing morbidity and mortality. In most transplant centers [[coronary angiography]] is currently used to screen and diagnose transplant associated [[coronary artery disease]].

==Coronary Angiography==
Previously, the diagnosis of CAV was made pathologically. However, with the advent of calcineurin-based immunosuppression post-cardiac transplant survival improved significantly and angiographic diagnosis became a standard. Currently, the International Society for Heart and Lung Transplantation (ISHLT) recommends annual invasive coronary angiography as the standard imaging technique to screen for CAV.<ref name="pmid20643330">{{cite journal| author=Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S et al.| title=The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 8 | pages= 914-56 | pmid=20643330 | doi=10.1016/j.healun.2010.05.034 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20643330 }} </ref> Angiographic evidence of coronary artery disease is very common after [[heart transplantation]]. In a multiinstitutional study by Constanzo et al it was demonstrated that by the end of 5 years after transplantation 42% of heart transplant subjects had angiographic evidence of graft coronary artery disease.<ref name="pmid9730422">{{cite journal| author=Costanzo MR, Naftel DC, Pritzker MR, Heilman JK, Boehmer JP, Brozena SC et al.| title=Heart transplant coronary artery disease detected by coronary angiography: a multiinstitutional study of preoperative donor and recipient risk factors. Cardiac Transplant Research Database. | journal=J Heart Lung Transplant | year= 1998 | volume= 17 | issue= 8 | pages= 744-53 | pmid=9730422 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9730422 }} </ref>

===Coronary Artery Morphology in CAV===
In contrast to native coronary artery disease where there is focal, eccentric narrowing of the coronary vessels, CAV involves a more diffuse process that manifests initially as intimal thickening followed by concentric, longitudinal lesions.<ref name="pmid2795279">{{cite journal| author=Johnson DE, Gao SZ, Schroeder JS, DeCampli WM, Billingham ME| title=The spectrum of coronary artery pathologic findings in human cardiac allografts. | journal=J Heart Transplant | year= 1989 | volume= 8 | issue= 5 | pages= 349-59 | pmid=2795279 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2795279 }} </ref><ref name="pmid2669276">{{cite journal| author=Billingham ME| title=Graft coronary disease: the lesions and the patients. | journal=Transplant Proc | year= 1989 | volume= 21 | issue= 4 | pages= 3665-6 | pmid=2669276 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2669276 }} </ref><ref name="pmid7798497">{{cite journal| author=Rickenbacher PR, Pinto FJ, Chenzbraun A, Botas J, Lewis NP, Alderman EL et al.| title=Incidence and severity of transplant coronary artery disease early and up to 15 years after transplantation as detected by intravascular ultrasound. | journal=J Am Coll Cardiol | year= 1995 | volume= 25 | issue= 1 | pages= 171-7 | pmid=7798497 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7798497 }} </ref><ref name="pmid16143236">{{cite journal| author=Haddad M, Pflugfelder PW, Guiraudon C, Novick RJ, McKenzie FN, Menkis A et al.| title=Angiographic, pathologic, and clinical relationships in coronary artery disease in cardiac allografts. | journal=J Heart Lung Transplant | year= 2005 | volume= 24 | issue= 9 | pages= 1218-25 | pmid=16143236 | doi=10.1016/j.healun.2004.08.016 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16143236 }} </ref> The earliest description of coronary artery morphology in CAV was given my Gao et al.<ref name="pmid3292629">{{cite journal| author=Gao SZ, Alderman EL, Schroeder JS, Silverman JF, Hunt SA| title=Accelerated coronary vascular disease in the heart transplant patient: coronary arteriographic findings. | journal=J Am Coll Cardiol | year= 1988 | volume= 12 | issue= 2 | pages= 334-40 | pmid=3292629 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3292629 }} </ref> According to the classification by Gao et al coronary lesions were classified as Type A, discrete stenosis, tubular stenosis, multiple stenoses in the proximal, middle and distal segments of coronary arteries; Type B, diffuse concentric narrowing of the coronary arteries with onset in the mid to distal segments; and Type C, diseased vessels, diffusely irregular with loss of small branches. However the nomenclature failed to provide prognostic significance of lesion classification. In 2010 the International Society for Heart and Lung Transplantation (ISHLT) proposed a standard nomenclature for CAV by integrating coronary angiographic findings with graft function and hemodynamics.

The ISHLT recommended standard nomenclature for CAV:<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>

{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Classification}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Severity}}
! style="width: 250px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Definition}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV0'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Not significant
| style="width: 250px; background: #F5F5F5; padding: 5px;"| No detectable angiographic lesions
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV1'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Mild
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or primary vessel with maximum lesion of 70%, or any branch stenosis of 70% (including diffuse narrowing) without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV2'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Moderate
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%; a single primary vessel 70%, or isolated branch stenosis of 70% in branches of 2 systems, without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV3'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Severe
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or 2 or more primary vessels 70% stenosis, or isolated branch stenosis 70% in all 3 systems; or ISHLT CAV1 or CAV2 with allograft dysfunction (defined as left ventricular ejection fraction >45%, usually in the presence of regional wall motion abnormalities) or evidence of significant restrictive physiology
|}

* A “primary vessel” denotes the proximal and middle 33% of the left anterior descending artery, the left circumflex, the ramus, and the dominant or codominant right coronary artery with the posterior descending and posterolateral branches. A “secondary branch vessel” includes the distal 33% of the primary vessels or any segment within a large septal perforator, diagonals, and obtuse marginal branches or any portion of a nondominant right coronary artery. Restrictive cardiac allograft physiology is defined as symptomatic heart failure with echocardiographic E to A velocity ratio of 2 (1.5 in children), shortened isovolumetric relaxation time (60 ms), shortened deceleration time (150 ms), or restrictive hemodynamic values (right atrial pressure 12 mm Hg, pulmonary capillary wedge pressure 25 mm Hg, cardiac index 2 l/min/m2). Adapted from the 2010 ISHLT consensus statement for recommended nomenclature of CAV

===Advantages===
# Wide acceptability<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>
# Reduced healthcare cost compared with other novel intracoronary imaging techniques
# Ease of performance

===Limitations===
# Lower [[sensitivity]] compared with histopathological studies, [[intravascular ultrasound]] ([[IVUS]]) and [[optical coherence tomography]] ([[OCT]]), especially in detecting early-stage CAV<ref name="pmid11243599">{{cite journal| author=Nissen S| title=Coronary angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 2001 | volume= 87 | issue= 4A | pages= 15A-20A | pmid=11243599 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11243599 }} </ref><ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref><ref name="pmid10363681">{{cite journal| author=Spes CH, Klauss V, Rieber J, Schnaack SD, Tammen AR, Uberfuhr P et al.| title=Functional and morphological findings in heart transplant recipients with a normal coronary angiogram: an analysis by dobutamine stress echocardiography, intracoronary Doppler and intravascular ultrasound. | journal=J Heart Lung Transplant | year= 1999 | volume= 18 | issue= 5 | pages= 391-8 | pmid=10363681 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10363681 }} </ref><ref name="pmid15862431">{{cite journal| author=Tuzcu EM, Kapadia SR, Sachar R, Ziada KM, Crowe TD, Feng J et al.| title=Intravascular ultrasound evidence of angiographically silent progression in coronary atherosclerosis predicts long-term morbidity and mortality after cardiac transplantation. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 9 | pages= 1538-42 | pmid=15862431 | doi=10.1016/j.jacc.2004.12.076 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15862431 }} </ref> Coronary angiography assesses only the arterial lumen but not the wall per se. Studies have demonstrated that early after heart transplantation disease pathology is confined to coronary arterial wall with minimal narrowing of the lumen.<ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref>
# Risk of [[contrast-induced nephropathy|contrast nephropathy]] in [[heart transplant]] subjects in whom [[chronic renal failure]] is a usual comorbidity<ref name="pmid10770975">{{cite journal| author=Lindelöw B, Bergh CH, Herlitz H, Waagstein F| title=Predictors and evolution of renal function during 9 years following heart transplantation. | journal=J Am Soc Nephrol | year= 2000 | volume= 11 | issue= 5 | pages= 951-7 | pmid=10770975 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10770975 }} </ref>

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy coronary angiography

2014-08-04T20:55:54Z

Raviteja Reddy Guddeti: /* Limitations */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Early diagnosis of cardiac allograft vasculopathy (CAV) is of utmost importance as it allows alterations to optimal immunosuppression and risk factor modification prolonging graft survival and reducing morbidity and mortality. In most transplant centers [[coronary angiography]] is currently used to screen and diagnose transplant associated [[coronary artery disease]].

==Coronary Angiography==
Previously, the diagnosis of CAV was made pathologically. However, with the advent of calcineurin-based immunosuppression post-cardiac transplant survival improved significantly and angiographic diagnosis became a standard. Currently, the International Society for Heart and Lung Transplantation (ISHLT) recommends annual invasive coronary angiography as the standard imaging technique to screen for CAV.<ref name="pmid20643330">{{cite journal| author=Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S et al.| title=The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 8 | pages= 914-56 | pmid=20643330 | doi=10.1016/j.healun.2010.05.034 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20643330 }} </ref> Angiographic evidence of coronary artery disease is very common after [[heart transplantation]]. In a multiinstitutional study by Constanzo et al it was demonstrated that by the end of 5 years after transplantation 42% of heart transplant subjects had angiographic evidence of graft coronary artery disease.<ref name="pmid9730422">{{cite journal| author=Costanzo MR, Naftel DC, Pritzker MR, Heilman JK, Boehmer JP, Brozena SC et al.| title=Heart transplant coronary artery disease detected by coronary angiography: a multiinstitutional study of preoperative donor and recipient risk factors. Cardiac Transplant Research Database. | journal=J Heart Lung Transplant | year= 1998 | volume= 17 | issue= 8 | pages= 744-53 | pmid=9730422 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9730422 }} </ref>

===Coronary Artery Morphology in CAV===
In contrast to native coronary artery disease where there is focal, eccentric narrowing of the coronary vessels, CAV involves a more diffuse process that manifests initially as intimal thickening followed by concentric, longitudinal lesions.<ref name="pmid2795279">{{cite journal| author=Johnson DE, Gao SZ, Schroeder JS, DeCampli WM, Billingham ME| title=The spectrum of coronary artery pathologic findings in human cardiac allografts. | journal=J Heart Transplant | year= 1989 | volume= 8 | issue= 5 | pages= 349-59 | pmid=2795279 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2795279 }} </ref><ref name="pmid2669276">{{cite journal| author=Billingham ME| title=Graft coronary disease: the lesions and the patients. | journal=Transplant Proc | year= 1989 | volume= 21 | issue= 4 | pages= 3665-6 | pmid=2669276 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2669276 }} </ref><ref name="pmid7798497">{{cite journal| author=Rickenbacher PR, Pinto FJ, Chenzbraun A, Botas J, Lewis NP, Alderman EL et al.| title=Incidence and severity of transplant coronary artery disease early and up to 15 years after transplantation as detected by intravascular ultrasound. | journal=J Am Coll Cardiol | year= 1995 | volume= 25 | issue= 1 | pages= 171-7 | pmid=7798497 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7798497 }} </ref><ref name="pmid16143236">{{cite journal| author=Haddad M, Pflugfelder PW, Guiraudon C, Novick RJ, McKenzie FN, Menkis A et al.| title=Angiographic, pathologic, and clinical relationships in coronary artery disease in cardiac allografts. | journal=J Heart Lung Transplant | year= 2005 | volume= 24 | issue= 9 | pages= 1218-25 | pmid=16143236 | doi=10.1016/j.healun.2004.08.016 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16143236 }} </ref> The earliest description of coronary artery morphology in CAV was given my Gao et al.<ref name="pmid3292629">{{cite journal| author=Gao SZ, Alderman EL, Schroeder JS, Silverman JF, Hunt SA| title=Accelerated coronary vascular disease in the heart transplant patient: coronary arteriographic findings. | journal=J Am Coll Cardiol | year= 1988 | volume= 12 | issue= 2 | pages= 334-40 | pmid=3292629 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3292629 }} </ref> According to the classification by Gao et al coronary lesions were classified as Type A, discrete stenosis, tubular stenosis, multiple stenoses in the proximal, middle and distal segments of coronary arteries; Type B, diffuse concentric narrowing of the coronary arteries with onset in the mid to distal segments; and Type C, diseased vessels, diffusely irregular with loss of small branches. However the nomenclature failed to provide prognostic significance of lesion classification. In 2010 the International Society for Heart and Lung Transplantation (ISHLT) proposed a standard nomenclature for CAV by integrating coronary angiographic findings with graft function and hemodynamics.

The ISHLT recommended standard nomenclature for CAV:<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>

{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 50px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Classification}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Severity}}
! style="width: 250px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Definition}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV0'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Not significant
| style="width: 250px; background: #F5F5F5; padding: 5px;"| No detectable angiographic lesions
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV1'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Mild
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or primary vessel with maximum lesion of 70%, or any branch stenosis of 70% (including diffuse narrowing) without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV2'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Moderate
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%; a single primary vessel 70%, or isolated branch stenosis of 70% in branches of 2 systems, without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV3'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Severe
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or 2 or more primary vessels 70% stenosis, or isolated branch stenosis 70% in all 3 systems; or ISHLT CAV1 or CAV2 with allograft dysfunction (defined as left ventricular ejection fraction >45%, usually in the presence of regional wall motion abnormalities) or evidence of significant restrictive physiology
|}

* A “primary vessel” denotes the proximal and middle 33% of the left anterior descending artery, the left circumflex, the ramus, and the dominant or codominant right coronary artery with the posterior descending and posterolateral branches. A “secondary branch vessel” includes the distal 33% of the primary vessels or any segment within a large septal perforator, diagonals, and obtuse marginal branches or any portion of a nondominant right coronary artery. Restrictive cardiac allograft physiology is defined as symptomatic heart failure with echocardiographic E to A velocity ratio of 2 (1.5 in children), shortened isovolumetric relaxation time (60 ms), shortened deceleration time (150 ms), or restrictive hemodynamic values (right atrial pressure 12 mm Hg, pulmonary capillary wedge pressure 25 mm Hg, cardiac index 2 l/min/m2). Adapted from the 2010 ISHLT consensus statement for recommended nomenclature of CAV

===Advantages===
# Wide acceptability<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>
# Reduced healthcare cost compared with other novel intracoronary imaging techniques
# Ease of performance

===Limitations===
# Lower [[sensitivity]] compared with histopathological studies, [[intravascular ultrasound]] ([[IVUS]]) and [[optical coherence tomography]] ([[OCT]]), especially in detecting early-stage CAV<ref name="pmid11243599">{{cite journal| author=Nissen S| title=Coronary angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 2001 | volume= 87 | issue= 4A | pages= 15A-20A | pmid=11243599 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11243599 }} </ref><ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref><ref name="pmid10363681">{{cite journal| author=Spes CH, Klauss V, Rieber J, Schnaack SD, Tammen AR, Uberfuhr P et al.| title=Functional and morphological findings in heart transplant recipients with a normal coronary angiogram: an analysis by dobutamine stress echocardiography, intracoronary Doppler and intravascular ultrasound. | journal=J Heart Lung Transplant | year= 1999 | volume= 18 | issue= 5 | pages= 391-8 | pmid=10363681 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10363681 }} </ref><ref name="pmid15862431">{{cite journal| author=Tuzcu EM, Kapadia SR, Sachar R, Ziada KM, Crowe TD, Feng J et al.| title=Intravascular ultrasound evidence of angiographically silent progression in coronary atherosclerosis predicts long-term morbidity and mortality after cardiac transplantation. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 9 | pages= 1538-42 | pmid=15862431 | doi=10.1016/j.jacc.2004.12.076 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15862431 }} </ref> Coronary angiography assesses only the arterial lumen but not the wall per se. Studies have demonstrated that early after heart transplantation disease pathology is confined to coronary arterial wall with minimal narrowing of the lumen.<ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref>
# Risk of [[contrast-induced nephropathy|contrast nephropathy]] in [[heart transplant]] subjects in whom [[chronic renal failure]] is a usual comorbidity<ref name="pmid10770975">{{cite journal| author=Lindelöw B, Bergh CH, Herlitz H, Waagstein F| title=Predictors and evolution of renal function during 9 years following heart transplantation. | journal=J Am Soc Nephrol | year= 2000 | volume= 11 | issue= 5 | pages= 951-7 | pmid=10770975 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10770975 }} </ref>

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy coronary angiography

2014-08-04T20:53:27Z

Raviteja Reddy Guddeti: /* Coronary Artery Morphology in CAV */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Early diagnosis of cardiac allograft vasculopathy (CAV) is of utmost importance as it allows alterations to optimal immunosuppression and risk factor modification prolonging graft survival and reducing morbidity and mortality. In most transplant centers [[coronary angiography]] is currently used to screen and diagnose transplant associated [[coronary artery disease]].

==Coronary Angiography==
Previously, the diagnosis of CAV was made pathologically. However, with the advent of calcineurin-based immunosuppression post-cardiac transplant survival improved significantly and angiographic diagnosis became a standard. Currently, the International Society for Heart and Lung Transplantation (ISHLT) recommends annual invasive coronary angiography as the standard imaging technique to screen for CAV.<ref name="pmid20643330">{{cite journal| author=Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S et al.| title=The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 8 | pages= 914-56 | pmid=20643330 | doi=10.1016/j.healun.2010.05.034 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20643330 }} </ref> Angiographic evidence of coronary artery disease is very common after [[heart transplantation]]. In a multiinstitutional study by Constanzo et al it was demonstrated that by the end of 5 years after transplantation 42% of heart transplant subjects had angiographic evidence of graft coronary artery disease.<ref name="pmid9730422">{{cite journal| author=Costanzo MR, Naftel DC, Pritzker MR, Heilman JK, Boehmer JP, Brozena SC et al.| title=Heart transplant coronary artery disease detected by coronary angiography: a multiinstitutional study of preoperative donor and recipient risk factors. Cardiac Transplant Research Database. | journal=J Heart Lung Transplant | year= 1998 | volume= 17 | issue= 8 | pages= 744-53 | pmid=9730422 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9730422 }} </ref>

===Coronary Artery Morphology in CAV===
In contrast to native coronary artery disease where there is focal, eccentric narrowing of the coronary vessels, CAV involves a more diffuse process that manifests initially as intimal thickening followed by concentric, longitudinal lesions.<ref name="pmid2795279">{{cite journal| author=Johnson DE, Gao SZ, Schroeder JS, DeCampli WM, Billingham ME| title=The spectrum of coronary artery pathologic findings in human cardiac allografts. | journal=J Heart Transplant | year= 1989 | volume= 8 | issue= 5 | pages= 349-59 | pmid=2795279 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2795279 }} </ref><ref name="pmid2669276">{{cite journal| author=Billingham ME| title=Graft coronary disease: the lesions and the patients. | journal=Transplant Proc | year= 1989 | volume= 21 | issue= 4 | pages= 3665-6 | pmid=2669276 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2669276 }} </ref><ref name="pmid7798497">{{cite journal| author=Rickenbacher PR, Pinto FJ, Chenzbraun A, Botas J, Lewis NP, Alderman EL et al.| title=Incidence and severity of transplant coronary artery disease early and up to 15 years after transplantation as detected by intravascular ultrasound. | journal=J Am Coll Cardiol | year= 1995 | volume= 25 | issue= 1 | pages= 171-7 | pmid=7798497 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7798497 }} </ref><ref name="pmid16143236">{{cite journal| author=Haddad M, Pflugfelder PW, Guiraudon C, Novick RJ, McKenzie FN, Menkis A et al.| title=Angiographic, pathologic, and clinical relationships in coronary artery disease in cardiac allografts. | journal=J Heart Lung Transplant | year= 2005 | volume= 24 | issue= 9 | pages= 1218-25 | pmid=16143236 | doi=10.1016/j.healun.2004.08.016 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16143236 }} </ref> The earliest description of coronary artery morphology in CAV was given my Gao et al.<ref name="pmid3292629">{{cite journal| author=Gao SZ, Alderman EL, Schroeder JS, Silverman JF, Hunt SA| title=Accelerated coronary vascular disease in the heart transplant patient: coronary arteriographic findings. | journal=J Am Coll Cardiol | year= 1988 | volume= 12 | issue= 2 | pages= 334-40 | pmid=3292629 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3292629 }} </ref> According to the classification by Gao et al coronary lesions were classified as Type A, discrete stenosis, tubular stenosis, multiple stenoses in the proximal, middle and distal segments of coronary arteries; Type B, diffuse concentric narrowing of the coronary arteries with onset in the mid to distal segments; and Type C, diseased vessels, diffusely irregular with loss of small branches. However the nomenclature failed to provide prognostic significance of lesion classification. In 2010 the International Society for Heart and Lung Transplantation (ISHLT) proposed a standard nomenclature for CAV by integrating coronary angiographic findings with graft function and hemodynamics.

The ISHLT recommended standard nomenclature for CAV:<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>

{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 50px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Classification}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Severity}}
! style="width: 250px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Definition}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV0'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Not significant
| style="width: 250px; background: #F5F5F5; padding: 5px;"| No detectable angiographic lesions
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV1'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Mild
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or primary vessel with maximum lesion of 70%, or any branch stenosis of 70% (including diffuse narrowing) without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV2'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Moderate
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%; a single primary vessel 70%, or isolated branch stenosis of 70% in branches of 2 systems, without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV3'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Severe
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or 2 or more primary vessels 70% stenosis, or isolated branch stenosis 70% in all 3 systems; or ISHLT CAV1 or CAV2 with allograft dysfunction (defined as left ventricular ejection fraction >45%, usually in the presence of regional wall motion abnormalities) or evidence of significant restrictive physiology
|}

* A “primary vessel” denotes the proximal and middle 33% of the left anterior descending artery, the left circumflex, the ramus, and the dominant or codominant right coronary artery with the posterior descending and posterolateral branches. A “secondary branch vessel” includes the distal 33% of the primary vessels or any segment within a large septal perforator, diagonals, and obtuse marginal branches or any portion of a nondominant right coronary artery. Restrictive cardiac allograft physiology is defined as symptomatic heart failure with echocardiographic E to A velocity ratio of 2 (1.5 in children), shortened isovolumetric relaxation time (60 ms), shortened deceleration time (150 ms), or restrictive hemodynamic values (right atrial pressure 12 mm Hg, pulmonary capillary wedge pressure 25 mm Hg, cardiac index 2 l/min/m2). Adapted from the 2010 ISHLT consensus statement for recommended nomenclature of CAV

===Advantages===
# Wide acceptability<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>
# Reduced healthcare cost compared with other novel intracoronary imaging techniques
# Ease of performance

===Limitations===
# Lower [[sensitivity]] compared with histopathological studies, [[intravascular ultrasound]] ([[IVUS]]) and [[optical coherence tomography]] ([[OCT]]), especially in detecting early-stage CAV<ref name="pmid11243599">{{cite journal| author=Nissen S| title=Coronary angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 2001 | volume= 87 | issue= 4A | pages= 15A-20A | pmid=11243599 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11243599 }} </ref><ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref><ref name="pmid10363681">{{cite journal| author=Spes CH, Klauss V, Rieber J, Schnaack SD, Tammen AR, Uberfuhr P et al.| title=Functional and morphological findings in heart transplant recipients with a normal coronary angiogram: an analysis by dobutamine stress echocardiography, intracoronary Doppler and intravascular ultrasound. | journal=J Heart Lung Transplant | year= 1999 | volume= 18 | issue= 5 | pages= 391-8 | pmid=10363681 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10363681 }} </ref><ref name="pmid15862431">{{cite journal| author=Tuzcu EM, Kapadia SR, Sachar R, Ziada KM, Crowe TD, Feng J et al.| title=Intravascular ultrasound evidence of angiographically silent progression in coronary atherosclerosis predicts long-term morbidity and mortality after cardiac transplantation. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 9 | pages= 1538-42 | pmid=15862431 | doi=10.1016/j.jacc.2004.12.076 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15862431 }} </ref> Coronary angiography assesses only the arterial lumen but not the wall per se. Studies have demonstrated that early after heart transplantation disease pathology is confined to coronary arterial wall with minimal narrowing of the lumen.
# Risk of [[contrast-induced nephropathy|contrast nephropathy]] in [[heart transplant]] subjects in whom [[chronic renal failure]] is a usual comorbidity<ref name="pmid10770975">{{cite journal| author=Lindelöw B, Bergh CH, Herlitz H, Waagstein F| title=Predictors and evolution of renal function during 9 years following heart transplantation. | journal=J Am Soc Nephrol | year= 2000 | volume= 11 | issue= 5 | pages= 951-7 | pmid=10770975 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10770975 }} </ref>

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy coronary angiography

2014-08-04T20:52:33Z

Raviteja Reddy Guddeti: /* Coronary Artery Morphology in CAV */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Early diagnosis of cardiac allograft vasculopathy (CAV) is of utmost importance as it allows alterations to optimal immunosuppression and risk factor modification prolonging graft survival and reducing morbidity and mortality. In most transplant centers [[coronary angiography]] is currently used to screen and diagnose transplant associated [[coronary artery disease]].

==Coronary Angiography==
Previously, the diagnosis of CAV was made pathologically. However, with the advent of calcineurin-based immunosuppression post-cardiac transplant survival improved significantly and angiographic diagnosis became a standard. Currently, the International Society for Heart and Lung Transplantation (ISHLT) recommends annual invasive coronary angiography as the standard imaging technique to screen for CAV.<ref name="pmid20643330">{{cite journal| author=Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S et al.| title=The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 8 | pages= 914-56 | pmid=20643330 | doi=10.1016/j.healun.2010.05.034 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20643330 }} </ref> Angiographic evidence of coronary artery disease is very common after [[heart transplantation]]. In a multiinstitutional study by Constanzo et al it was demonstrated that by the end of 5 years after transplantation 42% of heart transplant subjects had angiographic evidence of graft coronary artery disease.<ref name="pmid9730422">{{cite journal| author=Costanzo MR, Naftel DC, Pritzker MR, Heilman JK, Boehmer JP, Brozena SC et al.| title=Heart transplant coronary artery disease detected by coronary angiography: a multiinstitutional study of preoperative donor and recipient risk factors. Cardiac Transplant Research Database. | journal=J Heart Lung Transplant | year= 1998 | volume= 17 | issue= 8 | pages= 744-53 | pmid=9730422 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9730422 }} </ref>

===Coronary Artery Morphology in CAV===
In contrast to native coronary artery disease where there is focal, eccentric narrowing of the coronary vessels, CAV involves a more diffuse process that manifests initially as intimal thickening followed by concentric, longitudinal lesions.<ref name="pmid2795279">{{cite journal| author=Johnson DE, Gao SZ, Schroeder JS, DeCampli WM, Billingham ME| title=The spectrum of coronary artery pathologic findings in human cardiac allografts. | journal=J Heart Transplant | year= 1989 | volume= 8 | issue= 5 | pages= 349-59 | pmid=2795279 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2795279 }} </ref><ref name="pmid2669276">{{cite journal| author=Billingham ME| title=Graft coronary disease: the lesions and the patients. | journal=Transplant Proc | year= 1989 | volume= 21 | issue= 4 | pages= 3665-6 | pmid=2669276 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2669276 }} </ref><ref name="pmid7798497">{{cite journal| author=Rickenbacher PR, Pinto FJ, Chenzbraun A, Botas J, Lewis NP, Alderman EL et al.| title=Incidence and severity of transplant coronary artery disease early and up to 15 years after transplantation as detected by intravascular ultrasound. | journal=J Am Coll Cardiol | year= 1995 | volume= 25 | issue= 1 | pages= 171-7 | pmid=7798497 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7798497 }} </ref><ref name="pmid16143236">{{cite journal| author=Haddad M, Pflugfelder PW, Guiraudon C, Novick RJ, McKenzie FN, Menkis A et al.| title=Angiographic, pathologic, and clinical relationships in coronary artery disease in cardiac allografts. | journal=J Heart Lung Transplant | year= 2005 | volume= 24 | issue= 9 | pages= 1218-25 | pmid=16143236 | doi=10.1016/j.healun.2004.08.016 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16143236 }} </ref> The earliest description of coronary artery morphology in CAV was given my Gao et al.<ref name="pmid3292629">{{cite journal| author=Gao SZ, Alderman EL, Schroeder JS, Silverman JF, Hunt SA| title=Accelerated coronary vascular disease in the heart transplant patient: coronary arteriographic findings. | journal=J Am Coll Cardiol | year= 1988 | volume= 12 | issue= 2 | pages= 334-40 | pmid=3292629 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3292629 }} </ref> According to the classification by Gao et al coronary lesions were classified as Type A, discrete stenosis, tubular stenosis, multiple stenoses in the proximal, middle and distal segments of coronary arteries; Type B, diffuse concentric narrowing of the coronary arteries with onset in the mid to distal segments; and Type C, diseased vessels, diffusely irregular with loss of small branches. However the nomenclature failed to provide prognostic significance of lesion classification. In 2010 the International Society for Heart and Lung Transplantation (ISHLT) proposed a standard nomenclature for CAV by integrating coronary angiographic findings with graft function and hemodynamics.

The ISHLT recommended nomenclature for CAV:<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>

{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 50px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Classification}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Severity}}
! style="width: 250px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Definition}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV0'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Not significant
| style="width: 250px; background: #F5F5F5; padding: 5px;"| No detectable angiographic lesions
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV1'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Mild
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or primary vessel with maximum lesion of 70%, or any branch stenosis of 70% (including diffuse narrowing) without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV2'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Moderate
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%; a single primary vessel 70%, or isolated branch stenosis of 70% in branches of 2 systems, without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV3'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Severe
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or 2 or more primary vessels 70% stenosis, or isolated branch stenosis 70% in all 3 systems; or ISHLT CAV1 or CAV2 with allograft dysfunction (defined as left ventricular ejection fraction >45%, usually in the presence of regional wall motion abnormalities) or evidence of significant restrictive physiology
|}

* A “primary vessel” denotes the proximal and middle 33% of the left anterior descending artery, the left circumflex, the ramus, and the dominant or codominant right coronary artery with the posterior descending and posterolateral branches. A “secondary branch vessel” includes the distal 33% of the primary vessels or any segment within a large septal perforator, diagonals, and obtuse marginal branches or any portion of a nondominant right coronary artery. Restrictive cardiac allograft physiology is defined as symptomatic heart failure with echocardiographic E to A velocity ratio of 2 (1.5 in children), shortened isovolumetric relaxation time (60 ms), shortened deceleration time (150 ms), or restrictive hemodynamic values (right atrial pressure 12 mm Hg, pulmonary capillary wedge pressure 25 mm Hg, cardiac index 2 l/min/m2). Adapted from the 2010 ISHLT consensus statement for recommended nomenclature of CAV

===Advantages===
# Wide acceptability<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>
# Reduced healthcare cost compared with other novel intracoronary imaging techniques
# Ease of performance

===Limitations===
# Lower [[sensitivity]] compared with histopathological studies, [[intravascular ultrasound]] ([[IVUS]]) and [[optical coherence tomography]] ([[OCT]]), especially in detecting early-stage CAV<ref name="pmid11243599">{{cite journal| author=Nissen S| title=Coronary angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 2001 | volume= 87 | issue= 4A | pages= 15A-20A | pmid=11243599 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11243599 }} </ref><ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref><ref name="pmid10363681">{{cite journal| author=Spes CH, Klauss V, Rieber J, Schnaack SD, Tammen AR, Uberfuhr P et al.| title=Functional and morphological findings in heart transplant recipients with a normal coronary angiogram: an analysis by dobutamine stress echocardiography, intracoronary Doppler and intravascular ultrasound. | journal=J Heart Lung Transplant | year= 1999 | volume= 18 | issue= 5 | pages= 391-8 | pmid=10363681 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10363681 }} </ref><ref name="pmid15862431">{{cite journal| author=Tuzcu EM, Kapadia SR, Sachar R, Ziada KM, Crowe TD, Feng J et al.| title=Intravascular ultrasound evidence of angiographically silent progression in coronary atherosclerosis predicts long-term morbidity and mortality after cardiac transplantation. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 9 | pages= 1538-42 | pmid=15862431 | doi=10.1016/j.jacc.2004.12.076 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15862431 }} </ref> Coronary angiography assesses only the arterial lumen but not the wall per se. Studies have demonstrated that early after heart transplantation disease pathology is confined to coronary arterial wall with minimal narrowing of the lumen.
# Risk of [[contrast-induced nephropathy|contrast nephropathy]] in [[heart transplant]] subjects in whom [[chronic renal failure]] is a usual comorbidity<ref name="pmid10770975">{{cite journal| author=Lindelöw B, Bergh CH, Herlitz H, Waagstein F| title=Predictors and evolution of renal function during 9 years following heart transplantation. | journal=J Am Soc Nephrol | year= 2000 | volume= 11 | issue= 5 | pages= 951-7 | pmid=10770975 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10770975 }} </ref>

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy coronary angiography

2014-08-04T20:51:42Z

Raviteja Reddy Guddeti: /* Coronary Artery Morphology in CAV */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Early diagnosis of cardiac allograft vasculopathy (CAV) is of utmost importance as it allows alterations to optimal immunosuppression and risk factor modification prolonging graft survival and reducing morbidity and mortality. In most transplant centers [[coronary angiography]] is currently used to screen and diagnose transplant associated [[coronary artery disease]].

==Coronary Angiography==
Previously, the diagnosis of CAV was made pathologically. However, with the advent of calcineurin-based immunosuppression post-cardiac transplant survival improved significantly and angiographic diagnosis became a standard. Currently, the International Society for Heart and Lung Transplantation (ISHLT) recommends annual invasive coronary angiography as the standard imaging technique to screen for CAV.<ref name="pmid20643330">{{cite journal| author=Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S et al.| title=The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 8 | pages= 914-56 | pmid=20643330 | doi=10.1016/j.healun.2010.05.034 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20643330 }} </ref> Angiographic evidence of coronary artery disease is very common after [[heart transplantation]]. In a multiinstitutional study by Constanzo et al it was demonstrated that by the end of 5 years after transplantation 42% of heart transplant subjects had angiographic evidence of graft coronary artery disease.<ref name="pmid9730422">{{cite journal| author=Costanzo MR, Naftel DC, Pritzker MR, Heilman JK, Boehmer JP, Brozena SC et al.| title=Heart transplant coronary artery disease detected by coronary angiography: a multiinstitutional study of preoperative donor and recipient risk factors. Cardiac Transplant Research Database. | journal=J Heart Lung Transplant | year= 1998 | volume= 17 | issue= 8 | pages= 744-53 | pmid=9730422 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9730422 }} </ref>

===Coronary Artery Morphology in CAV===
In contrast to native coronary artery disease where there is focal, eccentric narrowing of the coronary vessels, CAV involves a more diffuse process that manifests initially as intimal thickening followed by concentric, longitudinal lesions.<ref name="pmid2795279">{{cite journal| author=Johnson DE, Gao SZ, Schroeder JS, DeCampli WM, Billingham ME| title=The spectrum of coronary artery pathologic findings in human cardiac allografts. | journal=J Heart Transplant | year= 1989 | volume= 8 | issue= 5 | pages= 349-59 | pmid=2795279 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2795279 }} </ref><ref name="pmid2669276">{{cite journal| author=Billingham ME| title=Graft coronary disease: the lesions and the patients. | journal=Transplant Proc | year= 1989 | volume= 21 | issue= 4 | pages= 3665-6 | pmid=2669276 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2669276 }} </ref><ref name="pmid7798497">{{cite journal| author=Rickenbacher PR, Pinto FJ, Chenzbraun A, Botas J, Lewis NP, Alderman EL et al.| title=Incidence and severity of transplant coronary artery disease early and up to 15 years after transplantation as detected by intravascular ultrasound. | journal=J Am Coll Cardiol | year= 1995 | volume= 25 | issue= 1 | pages= 171-7 | pmid=7798497 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7798497 }} </ref> The earliest description of coronary artery morphology in CAV was given my Gao et al.<ref name="pmid3292629">{{cite journal| author=Gao SZ, Alderman EL, Schroeder JS, Silverman JF, Hunt SA| title=Accelerated coronary vascular disease in the heart transplant patient: coronary arteriographic findings. | journal=J Am Coll Cardiol | year= 1988 | volume= 12 | issue= 2 | pages= 334-40 | pmid=3292629 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3292629 }} </ref> According to the classification by Gao et al coronary lesions were classified as Type A, discrete stenosis, tubular stenosis, multiple stenoses in the proximal, middle and distal segments of coronary arteries; Type B, diffuse concentric narrowing of the coronary arteries with onset in the mid to distal segments; and Type C, diseased vessels, diffusely irregular with loss of small branches. However the nomenclature failed to provide prognostic significance of lesion classification. In 2010 the International Society for Heart and Lung Transplantation (ISHLT) proposed a standard nomenclature for CAV by integrating coronary angiographic findings with graft function and hemodynamics.

The ISHLT recommended nomenclature for CAV:<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>

{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 50px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Classification}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Severity}}
! style="width: 250px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Definition}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV0'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Not significant
| style="width: 250px; background: #F5F5F5; padding: 5px;"| No detectable angiographic lesions
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV1'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Mild
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or primary vessel with maximum lesion of 70%, or any branch stenosis of 70% (including diffuse narrowing) without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV2'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Moderate
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%; a single primary vessel 70%, or isolated branch stenosis of 70% in branches of 2 systems, without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV3'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Severe
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or 2 or more primary vessels 70% stenosis, or isolated branch stenosis 70% in all 3 systems; or ISHLT CAV1 or CAV2 with allograft dysfunction (defined as left ventricular ejection fraction >45%, usually in the presence of regional wall motion abnormalities) or evidence of significant restrictive physiology
|}

* A “primary vessel” denotes the proximal and middle 33% of the left anterior descending artery, the left circumflex, the ramus, and the dominant or codominant right coronary artery with the posterior descending and posterolateral branches. A “secondary branch vessel” includes the distal 33% of the primary vessels or any segment within a large septal perforator, diagonals, and obtuse marginal branches or any portion of a nondominant right coronary artery. Restrictive cardiac allograft physiology is defined as symptomatic heart failure with echocardiographic E to A velocity ratio of 2 (1.5 in children), shortened isovolumetric relaxation time (60 ms), shortened deceleration time (150 ms), or restrictive hemodynamic values (right atrial pressure 12 mm Hg, pulmonary capillary wedge pressure 25 mm Hg, cardiac index 2 l/min/m2). Adapted from the 2010 ISHLT consensus statement for recommended nomenclature of CAV

===Advantages===
# Wide acceptability<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>
# Reduced healthcare cost compared with other novel intracoronary imaging techniques
# Ease of performance

===Limitations===
# Lower [[sensitivity]] compared with histopathological studies, [[intravascular ultrasound]] ([[IVUS]]) and [[optical coherence tomography]] ([[OCT]]), especially in detecting early-stage CAV<ref name="pmid11243599">{{cite journal| author=Nissen S| title=Coronary angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 2001 | volume= 87 | issue= 4A | pages= 15A-20A | pmid=11243599 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11243599 }} </ref><ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref><ref name="pmid10363681">{{cite journal| author=Spes CH, Klauss V, Rieber J, Schnaack SD, Tammen AR, Uberfuhr P et al.| title=Functional and morphological findings in heart transplant recipients with a normal coronary angiogram: an analysis by dobutamine stress echocardiography, intracoronary Doppler and intravascular ultrasound. | journal=J Heart Lung Transplant | year= 1999 | volume= 18 | issue= 5 | pages= 391-8 | pmid=10363681 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10363681 }} </ref><ref name="pmid15862431">{{cite journal| author=Tuzcu EM, Kapadia SR, Sachar R, Ziada KM, Crowe TD, Feng J et al.| title=Intravascular ultrasound evidence of angiographically silent progression in coronary atherosclerosis predicts long-term morbidity and mortality after cardiac transplantation. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 9 | pages= 1538-42 | pmid=15862431 | doi=10.1016/j.jacc.2004.12.076 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15862431 }} </ref> Coronary angiography assesses only the arterial lumen but not the wall per se. Studies have demonstrated that early after heart transplantation disease pathology is confined to coronary arterial wall with minimal narrowing of the lumen.
# Risk of [[contrast-induced nephropathy|contrast nephropathy]] in [[heart transplant]] subjects in whom [[chronic renal failure]] is a usual comorbidity<ref name="pmid10770975">{{cite journal| author=Lindelöw B, Bergh CH, Herlitz H, Waagstein F| title=Predictors and evolution of renal function during 9 years following heart transplantation. | journal=J Am Soc Nephrol | year= 2000 | volume= 11 | issue= 5 | pages= 951-7 | pmid=10770975 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10770975 }} </ref>

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy coronary angiography

2014-08-04T20:50:20Z

Raviteja Reddy Guddeti: /* Coronary Artery Morphology in CAV */

__NOTOC__
{{Cardiac allograft vasculopathy}}
{{CMG}}; {{AE}} {{AN}}; {{RT}}

==Overview==
Early diagnosis of cardiac allograft vasculopathy (CAV) is of utmost importance as it allows alterations to optimal immunosuppression and risk factor modification prolonging graft survival and reducing morbidity and mortality. In most transplant centers [[coronary angiography]] is currently used to screen and diagnose transplant associated [[coronary artery disease]].

==Coronary Angiography==
Previously, the diagnosis of CAV was made pathologically. However, with the advent of calcineurin-based immunosuppression post-cardiac transplant survival improved significantly and angiographic diagnosis became a standard. Currently, the International Society for Heart and Lung Transplantation (ISHLT) recommends annual invasive coronary angiography as the standard imaging technique to screen for CAV.<ref name="pmid20643330">{{cite journal| author=Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S et al.| title=The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 8 | pages= 914-56 | pmid=20643330 | doi=10.1016/j.healun.2010.05.034 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20643330 }} </ref> Angiographic evidence of coronary artery disease is very common after [[heart transplantation]]. In a multiinstitutional study by Constanzo et al it was demonstrated that by the end of 5 years after transplantation 42% of heart transplant subjects had angiographic evidence of graft coronary artery disease.<ref name="pmid9730422">{{cite journal| author=Costanzo MR, Naftel DC, Pritzker MR, Heilman JK, Boehmer JP, Brozena SC et al.| title=Heart transplant coronary artery disease detected by coronary angiography: a multiinstitutional study of preoperative donor and recipient risk factors. Cardiac Transplant Research Database. | journal=J Heart Lung Transplant | year= 1998 | volume= 17 | issue= 8 | pages= 744-53 | pmid=9730422 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9730422 }} </ref>

===Coronary Artery Morphology in CAV===
In contrast to native coronary artery disease where there is focal, eccentric narrowing of the coronary vessels, CAV involves a more diffuse process that manifests initially as intimal thickening followed by concentric, longitudinal lesions.<ref name="pmid2795279">{{cite journal| author=Johnson DE, Gao SZ, Schroeder JS, DeCampli WM, Billingham ME| title=The spectrum of coronary artery pathologic findings in human cardiac allografts. | journal=J Heart Transplant | year= 1989 | volume= 8 | issue= 5 | pages= 349-59 | pmid=2795279 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2795279 }} </ref><ref name="pmid2669276">{{cite journal| author=Billingham ME| title=Graft coronary disease: the lesions and the patients. | journal=Transplant Proc | year= 1989 | volume= 21 | issue= 4 | pages= 3665-6 | pmid=2669276 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2669276 }} </ref> The earliest description of coronary artery morphology in CAV was given my Gao et al.<ref name="pmid3292629">{{cite journal| author=Gao SZ, Alderman EL, Schroeder JS, Silverman JF, Hunt SA| title=Accelerated coronary vascular disease in the heart transplant patient: coronary arteriographic findings. | journal=J Am Coll Cardiol | year= 1988 | volume= 12 | issue= 2 | pages= 334-40 | pmid=3292629 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3292629 }} </ref> According to the classification by Gao et al coronary lesions were classified as Type A, discrete stenosis, tubular stenosis, multiple stenoses in the proximal, middle and distal segments of coronary arteries; Type B, diffuse concentric narrowing of the coronary arteries with onset in the mid to distal segments; and Type C, diseased vessels, diffusely irregular with loss of small branches. However the nomenclature failed to provide prognostic significance of lesion classification. In 2010 the International Society for Heart and Lung Transplantation (ISHLT) proposed a standard nomenclature for CAV by integrating coronary angiographic findings with graft function and hemodynamics.

The ISHLT recommended nomenclature for CAV:<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>

{| style="border: 0px; font-size: 90%; margin: 0 18px;"
! style="width: 50px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Classification}}
! style="width: 100px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Severity}}
! style="width: 250px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Definition}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV0'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Not significant
| style="width: 250px; background: #F5F5F5; padding: 5px;"| No detectable angiographic lesions
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV1'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Mild
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or primary vessel with maximum lesion of 70%, or any branch stenosis of 70% (including diffuse narrowing) without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV2'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Moderate
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%; a single primary vessel 70%, or isolated branch stenosis of 70% in branches of 2 systems, without allograft dysfunction
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''ISHLT CAV3'''
| style="background: #DCDCDC; padding: 5px; text-align: center;"| Severe
| style="width: 250px; background: #F5F5F5; padding: 5px;"| Angiographic left main 50%, or 2 or more primary vessels 70% stenosis, or isolated branch stenosis 70% in all 3 systems; or ISHLT CAV1 or CAV2 with allograft dysfunction (defined as left ventricular ejection fraction >45%, usually in the presence of regional wall motion abnormalities) or evidence of significant restrictive physiology
|}

* A “primary vessel” denotes the proximal and middle 33% of the left anterior descending artery, the left circumflex, the ramus, and the dominant or codominant right coronary artery with the posterior descending and posterolateral branches. A “secondary branch vessel” includes the distal 33% of the primary vessels or any segment within a large septal perforator, diagonals, and obtuse marginal branches or any portion of a nondominant right coronary artery. Restrictive cardiac allograft physiology is defined as symptomatic heart failure with echocardiographic E to A velocity ratio of 2 (1.5 in children), shortened isovolumetric relaxation time (60 ms), shortened deceleration time (150 ms), or restrictive hemodynamic values (right atrial pressure 12 mm Hg, pulmonary capillary wedge pressure 25 mm Hg, cardiac index 2 l/min/m2). Adapted from the 2010 ISHLT consensus statement for recommended nomenclature of CAV

===Advantages===
# Wide acceptability<ref name="pmid20620917">{{cite journal| author=Mehra MR, Crespo-Leiro MG, Dipchand A, Ensminger SM, Hiemann NE, Kobashigawa JA et al.| title=International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. | journal=J Heart Lung Transplant | year= 2010 | volume= 29 | issue= 7 | pages= 717-27 | pmid=20620917 | doi=10.1016/j.healun.2010.05.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620917 }} </ref>
# Reduced healthcare cost compared with other novel intracoronary imaging techniques
# Ease of performance

===Limitations===
# Lower [[sensitivity]] compared with histopathological studies, [[intravascular ultrasound]] ([[IVUS]]) and [[optical coherence tomography]] ([[OCT]]), especially in detecting early-stage CAV<ref name="pmid11243599">{{cite journal| author=Nissen S| title=Coronary angiography and intravascular ultrasound. | journal=Am J Cardiol | year= 2001 | volume= 87 | issue= 4A | pages= 15A-20A | pmid=11243599 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11243599 }} </ref><ref name="pmid1537134">{{cite journal| author=St Goar FG, Pinto FJ, Alderman EL, Valantine HA, Schroeder JS, Gao SZ et al.| title=Intracoronary ultrasound in cardiac transplant recipients. In vivo evidence of "angiographically silent" intimal thickening. | journal=Circulation | year= 1992 | volume= 85 | issue= 3 | pages= 979-87 | pmid=1537134 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1537134 }} </ref><ref name="pmid10363681">{{cite journal| author=Spes CH, Klauss V, Rieber J, Schnaack SD, Tammen AR, Uberfuhr P et al.| title=Functional and morphological findings in heart transplant recipients with a normal coronary angiogram: an analysis by dobutamine stress echocardiography, intracoronary Doppler and intravascular ultrasound. | journal=J Heart Lung Transplant | year= 1999 | volume= 18 | issue= 5 | pages= 391-8 | pmid=10363681 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10363681 }} </ref><ref name="pmid15862431">{{cite journal| author=Tuzcu EM, Kapadia SR, Sachar R, Ziada KM, Crowe TD, Feng J et al.| title=Intravascular ultrasound evidence of angiographically silent progression in coronary atherosclerosis predicts long-term morbidity and mortality after cardiac transplantation. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 9 | pages= 1538-42 | pmid=15862431 | doi=10.1016/j.jacc.2004.12.076 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15862431 }} </ref> Coronary angiography assesses only the arterial lumen but not the wall per se. Studies have demonstrated that early after heart transplantation disease pathology is confined to coronary arterial wall with minimal narrowing of the lumen.
# Risk of [[contrast-induced nephropathy|contrast nephropathy]] in [[heart transplant]] subjects in whom [[chronic renal failure]] is a usual comorbidity<ref name="pmid10770975">{{cite journal| author=Lindelöw B, Bergh CH, Herlitz H, Waagstein F| title=Predictors and evolution of renal function during 9 years following heart transplantation. | journal=J Am Soc Nephrol | year= 2000 | volume= 11 | issue= 5 | pages= 951-7 | pmid=10770975 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10770975 }} </ref>

==References==
{{reflist|2}}
{{WH}}
{{WS}}

[[Category:Cardiology]]
[[Category:Surgery]]
[[Category:Immunology]]
[[Category:Disease]]

Cardiac allograft vasculopathy coronary angiography

2014-08-04T20:48:59Z

Raviteja Reddy Guddeti: /* Coronary Artery Morphology in CAV */

Cardiac allograft vasculopathy coronary angiography

2014-08-04T20:47:44Z

Raviteja Reddy Guddeti: /* Coronary Artery Morphology in CAV */

Cardiac allograft vasculopathy coronary angiography

2014-08-04T20:44:15Z

Raviteja Reddy Guddeti: /* Limitations */

Cardiac allograft vasculopathy coronary angiography

2014-08-04T20:41:06Z

Raviteja Reddy Guddeti: /* Coronary Artery Morphology in CAV */

Cardiac allograft vasculopathy coronary angiography

2014-08-04T20:40:35Z

Raviteja Reddy Guddeti: /* Coronary Angiography */

Cardiac allograft vasculopathy coronary angiography

2014-08-04T20:15:37Z

Raviteja Reddy Guddeti: /* Coronary Angiography */

Cardiac allograft vasculopathy coronary angiography

2014-08-04T20:04:30Z

Raviteja Reddy Guddeti: /* Coronary Angiography */

Cardiac allograft vasculopathy coronary angiography

2014-08-04T20:03:39Z

Raviteja Reddy Guddeti: /* Coronary Angiography */

Cardiac allograft vasculopathy coronary angiography

2014-08-04T20:02:41Z

Raviteja Reddy Guddeti: /* Coronary Angiography */

Cardiac allograft vasculopathy coronary angiography

2014-08-04T19:27:23Z

Raviteja Reddy Guddeti: /* Limitations */

Cardiac allograft vasculopathy coronary angiography

2014-08-04T19:26:15Z

Raviteja Reddy Guddeti: /* Limitations */

Cardiac allograft vasculopathy coronary angiography

2014-08-04T15:59:10Z

Raviteja Reddy Guddeti: /* Advantages */