Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, California.
Departments of Imaging and Medicine, Cedars-Sinai Smidt Heart Institute, Los Angeles, California; Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
JACC Cardiovasc Imaging. 2018 Oct;11(10):1514-1530. doi: 10.1016/j.jcmg.2018.06.019.
Heart transplantation is an accepted treatment for select patients with end-stage heart failure. Improvements to immunosuppressive therapies and patient management have increased the half-life of heart transplant patients to over 10 years. Despite this success, rejection remains the "Achilles heel" of heart transplantation. The early detection of acute rejection and cardiac allograft vasculopathy are paramount to avoiding graft loss. Unlike in kidney and liver transplantation, there are no clinically validated biomarkers for detecting heart transplant rejection. Existing methods for monitoring the cardiac allograft are invasive. The endomyocardial biopsy is the standard-of-care for monitoring for acute rejection but carries risks of complications, and histologic assessment is often subjective. Equally, intracoronary angiography remains the standard-of-care for detecting cardiac allograft vasculopathy, but it is invasive and less than ideally sensitive. Newer echocardiographic techniques, computed tomography, magnetic resonance, and positron emission tomography are less invasive than conventional biopsy and show promise in excluding rejection thereby potentially decreasing the frequency of biopsies in low-risk patients. Intravascular ultrasonography and optical coherence tomography, although still invasive, improve on the assessment of the coronary tree through increased resolution, evaluation of the microvasculature, and visualization of the vessel wall. This review outlines the invasive and noninvasive imaging modalities that are employed in the routine care of heart transplant patients and examines newer techniques that are under evaluation.
心脏移植是治疗晚期心力衰竭患者的一种公认的治疗方法。免疫抑制治疗和患者管理的改进提高了心脏移植患者的半衰期超过 10 年。尽管取得了这一成功，但排斥反应仍然是心脏移植的“阿喀琉斯之踵”。早期检测急性排斥反应和心脏移植物血管病对于避免移植物丢失至关重要。与肾和肝移植不同，目前还没有用于检测心脏移植排斥反应的临床验证的生物标志物。现有的监测心脏移植物的方法具有侵入性。心内膜心肌活检是监测急性排斥反应的标准方法，但存在并发症风险，组织学评估往往具有主观性。同样，冠状动脉造影仍然是检测心脏移植物血管病的标准方法，但它具有侵入性，且灵敏度不理想。较新的超声心动图技术、计算机断层扫描、磁共振和正电子发射断层扫描比传统活检的侵入性更小，在排除排斥反应方面显示出前景，从而有可能减少低风险患者的活检频率。血管内超声和光学相干断层扫描虽然仍然具有侵入性，但通过提高分辨率、评估微血管和可视化血管壁，改善了对冠状动脉树的评估。这篇综述概述了常规心脏移植患者护理中使用的侵入性和非侵入性成像方式，并检查了正在评估的新技术。
