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Cardiovascular Magnetic Resonance for Rejection Surveillance After Cardiac Transplantation

Research output: Contribution to journalArticlepeer-review

Chris Anthony, Muhammad Imran, Jim Pouliopoulos, Sam Emmanuel, James Iliff, Zhixin Liu, Kirsten Moffat, Min Ru Qiu, Catriona A. McLean, Christian Stehning, Valentina Puntmann, Vass Vassiliou, Tevfik F. Ismail, Ankur Gulati, Sanjay Prasad, Robert M. Graham, Jane McCrohon, Cameron Holloway, Eugene Kotlyar, Kavitha Muthiah & 4 more Anne M. Keogh, Christopher S. Hayward, Peter S. MacDonald, Andrew Jabbour

Original languageEnglish
Pages (from-to)1811-1824
Number of pages14
Issue number25
Published21 Jun 2022

Bibliographical note

Funding Information: Dr Keogh has conducted clinical trial research for Actelion, Pfizer, United Therapeutics, Arena, Acceleron, Bayer, Respira, GlaxoSmithKline, and Gilead. Dr Macdonald has received an institutional research grant from Novartis and has been on the advisory boards of Novartis and AstraZeneca. The other authors report no conflicts. Funding Information: Funding was provided by the National Heart Foundation of Australia, PhD student scholarship (1015420), Australian Department of Education, PhD student scholarship; and St. Vincent’s Clinic Foundation, Australia, study funds for imaging. Publisher Copyright: © 2022 American Heart Association, Inc.

King's Authors


Background: Endomyocardial biopsy (EMB) is the gold standard method for surveillance of acute cardiac allograft rejection (ACAR) despite its invasive nature. Cardiovascular magnetic resonance (CMR)-based myocardial tissue characterization allows detection of myocarditis. The feasibility of CMR-based surveillance for ACAR-induced myocarditis in the first year after heart transplantation is currently undescribed. Methods: CMR-based multiparametric mapping was initially assessed in a prospective cross-sectional fashion to establish agreement between CMR-and EMB-based ACAR and to determine CMR cutoff values between rejection grades. A prospective randomized noninferiority pilot study was then undertaken in adult orthotopic heart transplant recipients who were randomized at 4 weeks after orthotopic heart transplantation to either CMR-or EMB-based rejection surveillance. Clinical end points were assessed at 52 weeks. Results: Four hundred one CMR studies and 354 EMB procedures were performed in 106 participants. Forty heart transplant recipients were randomized. CMR-based multiparametric assessment was highly reproducible and reliable at detecting ACAR (area under the curve, 0.92; sensitivity, 93%; specificity, 92%; negative predictive value, 99%) with greater specificity and negative predictive value than either T1 or T2 parametric CMR mapping alone. High-grade rejection occurred in similar numbers of patients in each randomized group (CMR, n=7; EMB, n=8; P=0.74). Despite similarities in immunosuppression requirements, kidney function, and mortality between groups, the rates of hospitalization (9 of 20 [45%] versus 18 of 20 [90%]; odds ratio, 0.091; P=0.006) and infection (7 of 20 [35%] versus 14 of 20 [70%]; odds ratio, 0.192; P=0,019) were lower in the CMR group. On 15 occasions (6%), patients who were randomized to the CMR arm underwent EMB for clarification or logistic reasons, representing a 94% reduction in the requirement for EMB-based surveillance. Conclusions: A noninvasive CMR-based surveillance strategy for ACAR in the first year after orthotopic heart transplantation is feasible compared with EMB-based surveillance. Registration: HREC/13/SVH/66 and HREC/17/SVH/80. Australian New Zealand Clinical Trials Registry: ACTRN12618000672257.

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