Research ArticleCardiovascular

Comparative Prognostic and Diagnostic Value of Myocardial Blood Flow and Myocardial Flow Reserve After Cardiac Transplantation

Robert J.H. Miller, Osamu Manabe, Balaji Tamarappoo, Sean Hayes, John D. Friedman, Piotr J. Slomka, Jignesh Patel, Jon A. Kobashigawa and Daniel S. Berman
Journal of Nuclear Medicine February 2020, 61 (2) 249-255; DOI: https://doi.org/10.2967/jnumed.119.229625

Article Figures & Data

Figures

  • FIGURE 1.
    FIGURE 1.

    Receiver-operating-characteristic curves for diagnosing CAV ≥ grade 2. There was no difference between uncorrected MFR AUC and stress MBF AUC (P = 0.499) or corrected MFR AUC (P = 0.310).

  • FIGURE 2.
    FIGURE 2.

    Kaplan–Meier survival curves for all-cause mortality stratified by presence of abnormal regional perfusion. Patients with SSS ≥ 4 were more likely to experience all-cause mortality during follow-up (log-rank P = 0.017).

  • FIGURE 3.
    FIGURE 3.

    Kaplan–Meier survival curves for all-cause mortality stratified by quantitative PET results.

  • FIGURE 4.
    FIGURE 4.

    Receiver-operating-characteristic curves for identifying all-cause mortality during follow-up. Uncorrected MFR AUC was significantly larger than stress MBF AUC (P = 0.047). There was no significant difference between uncorrected MFR AUC and corrected MFR AUC (P = 0.681).

Tables

  • TABLE 1

    Baseline Population Characteristics

    CharacteristicNo death (n = 73)Death (n = 26)P
    Age (y)66.7 ± 10.574.0 ± 7.30.001
    Male54 (74.0%)21 (80.8%)0.599
    Age at transplantation (y)54.3 ± 11.161.9 ± 6.50.001
    Donor age (y)30.2 ± 11.935.4 ± 10.70.089
    Time after transplantation (y)12.5 ± 5.212.5 ± 5.40.977
    Body mass index (kg/m2)26.5 ± 5.625.8 ± 5.00.560
    Hypertension62 (84.9%)19 (73.1%)0.236
    Diabetes31 (42.5%)15 (57.7%)0.252
    Dyslipidemia53 (72.6%)21 (80.8%)0.600
    Former smoker4 (5.5%)2 (7.7%)0.651
    Renal failure7 (9.6%)4 (15.4%)0.472
    CAV grade* (0/1/2/3)46/17/5/313/6/2/40.489
    Cytomegalovirus viremia10 (13.7%)3 (11.5%)1.000
    History of acute cellular rejection10 (13.7%)5 (19.2%)0.531
    History of antibody-mediated rejection4 (5.5%)4 (15.4%)0.154
    Medication use
     Aspirin39 (53.4%)16 (61.5%)0.501
     β-blockers32 (43.8%)9 (34.6%)0.490
     Angiotensin-converting inhibitor or receptor blocker36 (49.3%)11 (42.3%)0.649
     Diuretics16 (21.9%)9 (34.6%)0.292
     Statins58 (79.5%)16 (61.5%)0.113
     Calcineurin inhibitor63 (86.3%)22 (84.6%)1.000
     Mammalian target of rapamycin inhibitor32 (43.8%)9 (34.6%)0.490

    • ↵* No death (n = 71); death (n = 25).

    • Data are expressed as number followed by percentage in parentheses or as mean ± SD.

  • TABLE 2

    Imaging Characteristics

    CharacteristicNo death (n = 73)Death (n = 26)P
    Resting heart rate81.88 ± 12.581.5 ± 12.80.980
    Rate–pressure product (bpm × mm Hg)10,895 ± 2,22911,122 ± 1,6270.635
    Resting LVEF (%)65.4 ± 9.756.8 ± 13.1<0.001
    82Rb semiquantitative imaging
     SRS0 (0–0)0 (0–1)0.136
     SSS0 (0–2)0 (0–8)0.102
     SDS0 (0–1)0 (0–4)0.072
    82Rb quantitative imaging
     Rest total perfusion deficit0 (0–0.3)0.2 (0.0–1.5)0.018
     Stress total perfusion deficit1.1 (0.0–4.4)2.1 (0.6–7.9)0.111
     Ischemic total perfusion deficit1.1 (0.0–3.9)1.9 (0.5–5.8)0.200
     Rest MBF (mL/min/g)1.29 (1.06–1.44)1.29 (1.14–1.56)0.216
     Stress MBF (mL/min/g)2.88 (2.41–3.60)2.54 (1.71–3.24)0.024
     MFR2.37 (2.01–2.80)1.69 (1.28–2.19)<0.001

    • Data are expressed as mean ± SD or as median followed by IQR in parentheses.

  • TABLE 3

    Univariable and Multivariable Association with All-Cause Mortality

    VariableUnadjusted HRPAdjusted HRP
    Age1.08 (1.03–1.14)<0.0011.10 (1.04–1.17)0.001
    Male1.37 (0.52–3.65)0.523——
    Body mass index0.97 (0.80–1.05)0.442——
    LVEF0.95 (0.92–0.98)0.0010.98 (0.94–1.02)0.232
    Cardiac risk factors
     Hypertension0.54 (0.23–1.28)0.161——
     Diabetes1.83 (0.84–3.99)0.129——
     Dyslipidemia1.55 (0.58–.11)0.380——
     Renal failure1.68 (0.58–4.88)0.339——
     Cytomegalovirus viremia0.77 (0.23–2.55)0.666——
     Acute cellular rejection1.43 (0.54–3.79)0.474——
     Antibody-mediated rejection1.88 (0.84–4.20)0.124——
    PET parameters
     SRS1.15 (1.01–1.31)0.0330.71 (0.20–2.54)0.602
     SSS1.09 (1.03–1.15)0.0021.02 (0.29–3.54)0.976
     SDS1.15 (1.06–1.26)0.0011.22 (0.35–4.19)0.754
     Rest MBF1.81 (0.78–4.19)0.166——
     Stress MBF0.56 (0.35–0.90)0.0171.14 (0.64–2.05)0.656
     Uncorrected MFR*0.34 (0.19–0.62)<0.0010.30 (0.11–0.81)0.017
     Corrected MFR*0.44 (0.26–0.74)0.0020.43 (0.20–0.90)0.025

    • ↵* Multivariable analysis was performed separately with corrected and uncorrected MFR.

    • Data in parentheses are 95% CIs.

  • TABLE 4

    Diagnostic and Prognostic Values of Previously Reported Thresholds

    Diagnosis of CAV grade 2/3Annualized all-cause mortality rate
    CutoffAbnormal (n)SensitivitySpecificityAbnormalNormal
    MFR < 2.034 (34.3%)71.4%71.8%17.7%4.7%
    MFR < 1.7527 (27.3%)57.1%77.7%19.6%5.2%
    Stress MBF < 3.779 (79.8%)92.9%22.4%9.0%6.7%
    Stress MBF < 1.710 (10.1%)42.9%95.3%35.8%7.0%
    SSS > 132 (32.2%)64.3%72.9%12.3%7.0%
    SSS > 315 (15.2%)64.3%92.9%18.7%7.1%
    LVEF ≤ 4510 (10.1%)42.9%95.3%25.0%7.2%
    MBF < 1.7 and SSS > 1 or LVEF ≤ 458 (8.1%)42.9%97.7%60.7%6.8%
    SSS ≥ 4, LVEF ≤ 45 or MFR < 1.7536 (36.4%)71.4%69.4%15.4%5.0%
    LVEF ≤ 45% and MFR < 1.75*5 (5.1%)35.7%100.0%51.6%7.4%

    • ↵* Same patients would be identified using MBF < 1.7 and LVEF < 45%.

    • Uncorrected MFR was used because it was numerically superior in all models.

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