Allograft Vasculopathy
Accuracy of dobutamine tetrofosmin myocardial perfusion imaging for the noninvasive diagnosis of transplant coronary artery stenosis

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Abstract

Background: Exercise stress myocardial perfusion scintigraphy has been used for the diagnosis of transplant coronary artery stenosis (TCAS) in cardiac allograft recipients. However, the role of pharmacologic stress myocardial perfusion imaging has not been evaluated. Aim of the study is to assess the accuracy of dobutamine stress 99m technetium tetrofosmin myocardial perfusion imaging for the diagnosis of TCAS in heart transplant recipients.

Patients and methods

We studied 50 patients (age 56 ± 8 year, 45 men) at a mean of 6.4 ± 2.8 years after cardiac transplant with dobutamine (up to 40 ı̀g/kg/min) stress 99m technetium tetrofosmin SPECT. Resting images were acquired 24 hours after the stress study. Significant TCAS was defined as ≥50% luminal diameter stenosis by coronary angiography.

Results

Significant TCAS was detected in 30 patients (60%). Myocardial perfusion abnormalities (reversible and/or fixed defects) were detected in 27 of the 30 patients with and in 9 of the 20 patients without significant TCAS (sensitivity = 90%, CI 82-98, specificity = 55% CI 41-69, positive predictive value = 75%, CI 63-87, negative predictive value = 79%, CI 67-90 and accuracy = 76%, CI 64-88). Patients with multivessel TCAS had a larger stress perfusion defect score (5.6 ± 3.1 vs 3.2 ± 2.4, p < 0.05) compared to patients with single vessel TCAS. Among patients with abnormal perfusion who had no significant TCAS, 2 had lesions <50%, 2 had luminal irregularities and 5 had no abnormalities at angiography. Therefore specificity was 62% (8/13) in patients without any detectable angiographic abnormalities.

Conclusions

Dobutamine stress tetrofosmin myocardial perfusion imaging is a highly sensitive method for the detection of TCAS in recipients of cardiac allografts. The high negative predictive value of the test indicates that patients who demonstrate normal perfusion by this method may be excluded from further invasive studies.

Section snippets

Patient selection

The study population consisted of 50 recipients of cardiac allograft who underwent dobutamine stress 99m technetium tetrofosmin SPECT at a mean of 6.4 ± 2.8 (range 2–14) years after the transplantation and coronary angiography within 3 months from the dobutamine stress test. Mean age was 56 ± 8 years. There were 45 men and 5 women. Two patients had atypical chest pain. Risk factors for CAD were hypertension in 32 (64%) patients, diabetes mellitus in 5 (10%) patients, smoking in 6 (12%) patients

Dobutamine stress test

There was a significant increase of heart rate (93 ± 11 vs 142 ± 9 beats/minute, p < 0.0001), systolic blood pressure (144 ± 19 vs 151 ± 28 mm Hg, p < 0.01) and rate pressure product (13516 ± 3026 vs 21365 ± 4114, p < 0.0001) from rest to peak stress respectively. Two patients developed atypical and one patient developed typical chest pain during stress. The target heart rate (≥85% of the maximal exercise heart rate predicted for age) was reached in 41 patients (82%). Minor side effects were

Discussion

This is the first study, which evaluates the accuracy of dobutamine myocardial perfusion imaging for the non-invasive diagnosis of TCAS. Our data showed that dobutamine tetrofosmin myocardial perfusion SPECT imaging is a highly sensitive methods for the diagnosis of significant TCAS in patients studied 6.4 ± 2.8 (range 2–14) years after heart transplantation. Myocardial perfusion abnormalities were detected in 90% of patients with TCAS. The high sensitivity was shown in patients with single

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  • Cited by (39)

    • Emerging imaging techniques after cardiac transplantation

      2016, Journal of Heart and Lung Transplantation
    • Transplant coronary artery disease

      2010, JACC: Cardiovascular Interventions
    • The Role of Multimodality Cardiac Imaging in the Transplanted Heart

      2009, JACC: Cardiovascular Imaging
      Citation Excerpt :

      Moreover, the use of vasodilators with MPI may be limited in cardiac transplant recipients because the diffuse, microvascular CAV may impair the necessary increase in coronary flow reserve to trigger the flow heterogeneity to detect significant stenosis. Despite these observations, more recent studies using dipyridamole MPI have demonstrated comparable sensitivity (range 80% to 92%) and specificity (range 86% to 92%) to dobutamine stress MPI to detect CAV (46,52–54). Similar to DSE, the potential clinical usefulness of SPECT-MPI relates to its prognostic value.

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    This study was supported in part by the Department of Cardiology, Cairo University Hospital, Cairo, Egypt.

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