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  • 1 Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
  • | 2 Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland
  • | 3 Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
Open access

A 58-year-old male patient presented to our hospital for his yearly routine examination 6 years after orthotopic heart transplantation due to severe ischemic heart disease (the patient was part of a previously published case series 1). The patient was free of symptoms (New York Heart Association, NYHA, I). In ergospirometry, the patient reached 71% of the age-adjusted nominal value. Echocardiography showed a preserved left ventricular function (biplane ejection fraction 63%) without regional wall motion abnormalities. The cyclosporine level was in the target range (123 μg/l, target 100–150 μg/l). Endomyocardial biopsy showed no acute cellular rejection (International Society for Heart and Lung Transplantation, ISHLT, grade 0R, “no evidence of rejection”) after two previous episodes of cellular rejection (ISHLT grade 2R, “moderate rejection”, 24 days and 255 days after transplantation, respectively). Invasive coronary angiography did not show focal coronary artery stenosis. Cardiac magnetic resonance (MR) adenosine stress perfusion imaging showed a large area of myocardial hypoperfusion of the inferior and infero-septal wall (standard supply territory of the right coronary artery, RCA, ischemic burden 22%).

As shown in Fig. 1, retrospective analysis including calculations of the computed tomography (CT) derived fractional flow reserve (FFRCT) and 3D multimodal, multiparametric image fusion [1] explained these controversial findings: the inferior/infero-septal perfusion deficit correlated with a long, thin RCA with pathologic FFRCT values (0.68, threshold 0.8). The diffuse concentric narrowing of the RCA lumen was most probably caused by cardiac allograft vasculopathy (CAV) – a long term complication of heart transplant recipients [2]. CAV is characterized by fibrotic proliferation and intimal thickening leading to diffuse lumen restriction of the graft coronary arteries. As known from the literature, diffuse lumen narrowing can lead to flow restrictions similar to those resulting from focal stenosis of higher degree [3].

Fig. 1.
Fig. 1.

58-year-old male patient 6 years after heart transplantation. Conventional 2D readout of this patient's image data resulted in incoherent findings. In cardiac MR stress perfusion, an inferior/infero-septal area of hypoperfusion was described – without focal stenosis of the right coronary artery (RCA) in invasive coronary angiography. CT derived fractional flow reserve (FFRCT) in combination with 3D image fusion could help: the perfusion deficit in the standard supply territory of the RCA (asterisk) was most likely caused by a long and diffuse concentric lumen narrowing (arrowheads) that also resulted in pathologic FFRCT values. Note the aortic suture after orthotopic heart transplantation (dotted arrow).

Citation: Imaging IMAGING 12, 1; 10.1556/1647.2020.00005

This patient case highlights the importance of using complementary diagnostic tests in order to resolve apparently controversial findings. 3D fusion of CT and MR imaging can be advantageous for a correct and precise correlation of coronary disease with myocardial ischemia.

Funding source

The study was funded by Swiss National Science Foundation (CR3213_132671/1) and Bayer Healthcare.

References

  • [1]

    von Spiczak J, Mannil M, Model H, Schwemmer C, Kozerke S, Ruschitzka F, et al. : Multimodal multiparametric three-dimensional image fusion in coronary artery disease: Combining the best of two worlds. Radiol Cardiothorac Imaging 2020; 2(2): e190116. https://doi.org/10.1148/ryct.2020190116.

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  • [2]

    Chih S, Chong AY, Mielniczuk LM, Bhatt DL, Beanlands RSB: Allograft vasculopathy: The Achilles’ Heel of heart transplantation. J Am Coll Cardiol 2016; 68(1): 8091. https://doi.org/10.1016/j.jacc.2016.04.033.

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  • [3]

    Gould KL: Does coronary flow trump coronary anatomy?. JACC Cardiovasc Imaging 2009; 2(8): 10091023. https://doi.org/10.1016/j.jcmg.2009.06.004.

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    • Export Citation
  • [1]

    von Spiczak J, Mannil M, Model H, Schwemmer C, Kozerke S, Ruschitzka F, et al. : Multimodal multiparametric three-dimensional image fusion in coronary artery disease: Combining the best of two worlds. Radiol Cardiothorac Imaging 2020; 2(2): e190116. https://doi.org/10.1148/ryct.2020190116.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • [2]

    Chih S, Chong AY, Mielniczuk LM, Bhatt DL, Beanlands RSB: Allograft vasculopathy: The Achilles’ Heel of heart transplantation. J Am Coll Cardiol 2016; 68(1): 8091. https://doi.org/10.1016/j.jacc.2016.04.033.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • [3]

    Gould KL: Does coronary flow trump coronary anatomy?. JACC Cardiovasc Imaging 2009; 2(8): 10091023. https://doi.org/10.1016/j.jcmg.2009.06.004.

    • Crossref
    • Search Google Scholar
    • Export Citation

 

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Chair of the Editorial Board:
Béla MERKELY (Semmelweis University, Budapest, Hungary)

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Pál MAUROVICH-HORVAT (Semmelweis University, Budapest, Hungary)

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Tamás Zsigmond KINCSES (University of Szeged, Hungary)
Hildo LAMB (Leiden University, The Netherlands)
Denisa MURARU (Istituto Auxologico Italiano, IRCCS, Milan, Italy)
Ronak RAJANI (Guy’s and St Thomas’ NHS Foundation Trust, London, UK)

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Fabian BAMBERG (Department of Radiology, University Hospital Freiburg, Germany)
Péter BARSI (Semmelweis University, Budapest, Hungary)
Theodora BENEDEK (University of Medicine, Pharmacy, Sciences and Technology, Targu Mures, Romania)
Ronny BÜCHEL (University Hospital Zürich, Switzerland)
Filippo CADEMARTIRI (SDN IRCCS, Naples, Italy) Matteo CAMELI (University of Siena, Italy)
Csilla CELENG (University of Utrecht, The Netherlands)
Edit DÓSA (Semmelweis University, Budapest, Hungary)
Marco FRANCONE (La Sapienza University of Rome, Italy)
Viktor GÁL (OrthoPred Ltd., Győr, Hungary)
Alessia GIMELLI (Fondazione Toscana Gabriele Monasterio, Pisa, Italy)
Tamás GYÖRKE (Semmelweis Unversity, Budapest)
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Pál KAPOSI (Semmelweis University, Budapest, Hungary)
Mihaly KÁROLYI (University of Zürich, Switzerland)
Márton KOLOSSVÁRY (Semmelweis University, Budapest, Hungary)
Lajos KOZÁK (Semmelweis University, Budapest, Hungary)
Mariusz KRUK (Institute of Cardiology, Warsaw, Poland)
Zsuzsa LÉNARD (Semmelweis University, Budapest, Hungary)
Erica MAFFEI (ASUR Marche, Urbino, Marche, Italy)
Robert MANKA (University Hospital, Zürich, Switzerland)
Saima MUSHTAQ (Cardiology Center Monzino (IRCCS), Milan, Italy)
Gábor RUDAS (Semmelweis University, Budapest, Hungary)
Balázs RUZSICS (Royal Liverpool and Broadgreen University Hospital, UK)
Christopher L SCHLETT (Unievrsity Hospital Freiburg, Germany)
Bálint SZILVESZTER (Semmelweis University, Budapest, Hungary)
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Ádám TÁRNOKI (National Institute of Oncology, Budapest, Hungary)
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Anna BARITUSSIO (University of Padova, Italy)
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Edoardo CONTE (Centro Cardiologico Monzino IRCCS, Milan)
Réka FALUDI (University of Szeged, Hungary)
Andrea Igoren GUARICCI (University of Bari, Italy)
Marco GUGLIELMO (Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy)
Kristóf HISRCHBERG (University of Heidelberg, Germany)
Dénes HORVÁTHY (Semmelweis University, Budapest, Hungary)
Julia KARADY (Harvard Unversity, MA, USA)
Attila KOVÁCS (Semmelweis University, Budapest, Hungary)
Riccardo LIGA (Cardiothoracic and Vascular Department, Università di Pisa, Pisa, Italy)
Máté MAGYAR (Semmelweis University, Budapest, Hungary)
Giuseppe MUSCOGIURI (Centro Cardiologico Monzino IRCCS, Milan, Italy)
Anikó I NAGY (Semmelweis University, Budapest, Hungary)
Liliána SZABÓ (Semmelweis University, Budapest, Hungary)
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Imaging
Language English
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2020 (2009)
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