Left ventricular function and mass after orthotopic heart transplantation: a comparison of cardiovascular magnetic resonance with echocardiography

doi:10.1016/S1053-2498(00)00079-6

The Journal of Heart and Lung Transplantation

Volume 19, Issue 5, May 2000, Pages 444-452

https://doi.org/10.1016/S1053-2498(00)00079-6 Get rights and content

Abstract

Objective: We compared the assessment of left ventricular function and mass by M-mode echocardiography (echo) with fast breath-hold cardiovascular magnetic resonance (CMR) in patients who received orthotopic heart transplantation. We also sought to establish the reproducibility of breath-hold CMR in this patient population.

Method

We prospectively acquired 51 sets of echo and CMR data in 21 patients who had undergone orthotopic heart transplantation. We examined the intraobserver and interobserver reproducibility of breath-hold CMR in this group and compared it with published data. We compared the left ventricular ejection fraction (EF) and mass determined by echo with the CMR data.

Results

The average time between CMR and echo was 0 ± 7 days (mean ± SD), the time between each set of CMR–echo data acquisition was 5.1 ± 4.1 months. Cardiovascular magnetic resonance showed good reproducibility in this population, with intraobserver percentage variability of 2.2% ± 2.4% for EF and 3.2% ± 2.7% for mass, and interobserver percentage variability of 2.4% ± 1.9% for EF and 2.2% ± 1.9% for mass. The Bland-Altman limits of agreement between echo and CMR were wide for both EF (−9.6% to 15%) and mass, irrespective of the formula used (−61.3 to 198 g for the Bennett and Evans formula, −65.4 to 196.8 g for the American Society of Echocardiography (ASE) formula, −65.3 to 181 g for the Devereux formula, and −95.2 to 64.6 g for the Teichholz formula).

Conclusion

Fast-acquisition CMR is reproducible in recipients of transplanted hearts. We found poor agreement with the results of echo. The choice of technique will depend on local resources as well as the clinical importance of the result. Echo remains readily available and gives rapid assessment of volumes, EF, and mass. However, the good reproducibility of CMR may make it a more suitable technique for long-term follow-up of an individual or of a study population.

Section snippets

Patients and methods

We prospectively acquired 51 sets of CMR and echo data from 21 patients who had undergone orthotopic heart transplantation. The average time between CMR and echo was 0 ± 7 days. The time between each set of CMR–echo data acquisition was 5.0 ± 4.1 months. At the time of scanning, no patient had evidence of rejection on cardiac biopsy. The Royal Brompton and Harefield Hospital ethics committee approved the protocol, and all subjects gave written consent.

Reproducibility of CMR

The results are presented in Table I. We found no significant difference in the EF measured twice by the same observer (mean EF = 71% ± 7%, mean difference = −0.3% ± 2.2%), or by 2 different observers (mean EF = 70% ± 7%, mean difference = 0.4% ± 2%). Furthermore, the limits of agreement were narrow (−4.7% to 4 % and −3.6% to 4.4%, respectively).

The reproducibility of LV mass was also good with no significant difference in the mass measured twice by the same observer (mean mass = 205 ± 41 g,

Discussion

The main findings of this study are that CMR is feasible in the heart transplant population and that it provides highly reproducible measurements of left ventricular EF and mass. Furthermore, echo measurements showed poor agreement with CMR. Cardiovascular magnetic resonance, but not echo, was able to detect small changes over time in EF and mass.

Cardiovascular magnetic resonance offers a reproducible measure of ventricular function and mass that is not dependent on suitable acoustic windows

Conclusion

We have demonstrated that fast acquisition CMR is reproducible in recipients of transplanted hearts and found poor agreement with the M-mode echo measurements routinely used to assess LV function and mass. The highly reproducible results of CMR may allow early detection of changes that occur during graft rejection and provide an accurate assessment of long-term remodeling related to post-transplant hypertension and drug therapy.

Acknowledgements

Dr. N. Bellenger is supported by a grant from SmithKline Beecham, through the National Heart and Lung Institute, Imperial College, London, United Kingdom. This study was supported by the Wellcome Trust and Corda, the heart charity.

References (42)

L.E. Teichholz et al.
Problems in echocardiographic volume determinationsechocardiographic-angiographic correlations in the presence or absence of asynergy
Am J Cardiol
(1976)
J.D. Allison et al.
Measurement of left ventricular mass in hypertrophic cardiomyopathy using MRIcomparison with echo
Mag Reson Imaging
(1993)
L.E. Teichholz et al.
Problems in echocardiographic volume determinationsechocardiographic-angiographic correlations in the presence or absence of asynergy
Am J Cardiol
(1976)
T. Albrecht et al.
Hypertensive heart disease quantitative evaluation of response to therapy with cine MRI
Acad Radiol
(1997)
P.B. Bottini et al.
Magnetic resonance imaging compared to echocardiography to assess left ventricular mass in the hypertensive patient
Am J Hypertens
(1995)
A. Ganau et al.
Patterns of left ventricular hypertrophy and geometric remodelling in essential hypertension
J Am Coll Cardiol
(1992)
J.S. Gottdiener et al.
Should echocardiography be performed to assess effects of antihypertensive therapy? Test-retest reliability of echocardiography for measurement of left ventricular mass and function. J Am Coll Cardiol
(1995)
R.C. McKoy et al.
Left ventricular hypertrophy in cyclosporine-induced systemic hypertension after cardiac transplantation
Am J Cardiol
(1988)
D. Farge et al.
Effect of systemic hypertension on renal function and left ventricular hypertrophy in heart transplant recipients
J Am Coll Cardiol
(1990)
F.H.H. Leenen et al.
Blood pressure and left ventricular anatomy and function after heart transplantation
Am Heart J
(1991)

E.A. Gill et al.

Left ventricular mass increases during cardiac allograft vascular rejection

J Am Coll Cardiol

(1995)

C.B. Higgins

Which standard has the gold?

Am J Cardiol

(1992)

R.C. Semelka et al.

Interstudy reproducibility of dimensional and functional measurements between cine magnetic resonance imaging studies in the morphologically abnormal left ventricle

Am Heart J

(1990)

E. Ozdogen et al.

Factors influencing the development of hypertension after heart transplantation

J Heart Transplant

(1990)

J.D. Hospenpud et al.

Serial echo findings early after heart transplantationevidence for reversible right ventricular dysfunction and myocardial oedema

J Heart Transplant

(1987)

J. Gorcsan et al.

Echocardiographic profile of the transplanted human heart in clinically well recipients

J Heart Lung Transplant

(1992)

W.A. Zoghbi et al.

Serial changes in left ventricular mass of the donor’s heart early after transplantation (abstract)

J Am Coll Cardiol

(1998)

S. Globits et al.

Assessment of early left ventricular remodelling in orthotopic heart transplant recipients with cine magnetic resonance imagingpotential mechanisms

J Heart Lung Transplant

(1997)

G. Kronik et al.

Comparative value of eight M-mode echocardiographic formulas for determining left ventricular stroke volume

Circulation

(1979)

J. Mogelvang et al.

Assessment of left ventricular volumes by magnetic resonance in comparison with radionuclide angiography, contrast angiography and echocardiography

Eur Heart J

(1992)

J. Katz et al.

Estimation of human myocardial mass with MR imaging

Radiology

(1988)

Cited by (64)

Assessment of Cardiac Function
2018, Cardiovascular Magnetic Resonance: A Companion to Braunwald’s Heart Disease
The accurate and reproducible assessment of cardiac function is a fundamental aim of noninvasive cardiac imaging. It forms the foundation upon which much of the assessment and management of myocardial dysfunction, ischemia, viability, remodeling, valvular, and other cardiac disorders are based. In this chapter, we discuss the importance of the measurement of global cardiac function, compare techniques, show differences according to magnetic fields, provide a practical step-by-step guide to its assessment by cardiovascular magnetic resonance (CMR) and describe new techniques that can be used for the assessment of cardiac function.
Emerging imaging techniques after cardiac transplantation
2016, Journal of Heart and Lung Transplantation
Improvements in survival after cardiac transplantation have in part been driven by improved graft surveillance. Graft surveillance relies mainly on 3 techniques: coronary angiography, endomyocardial biopsy and echocardiography. Developments in invasive and non-invasive imaging technology have revolutionized assessment of the heart in both health and disease, offering new insights into tissue composition and myocardial metabolism. Herein we aim to review the strengths and weaknesses of these techniques, and summarize the evidence in the following 5 fields of cardiac imaging after transplantation: cardiovascular magnetic resonance; computed tomography; positron emission tomography; single-photon emission computed tomography; and optical coherence tomography and molecular imaging techniques.
Advances in imaging: The impact on the care of the adult with congenital heart disease
2011, Progress in Cardiovascular Diseases
Citation Excerpt :
Stress MRI (dipyridamole, adenosine, or dobutamine) can additionally allow evaluation of perfusion defects and coronary flow reserve. MRI is useful for delineating anatomy and physiology in patients following repair of CoA.27-31 Initial studies provided primarily static assessment of anatomy; however, more recently, MRI has been exploited to evaluate and assess physiology.30
Recent advances in pediatric cardiology have dramatically changed the landscape of the field of congenital heart disease. This changing field is placing new demands on imaging to plan medical management as well as identify the need for, and timing of, reintervention. There are a number of imaging modalities available to the clinician when it comes to these evaluations, including echocardiography, computed tomography, and cardiac magnetic resonance imaging; each having their strengths and unique contributions. This article will discuss the advances in the aforementioned imaging modalities over the past decade and highlight how these tools can provide guidelines on the management of adults with congenital heart disease.
Concentric left ventricular hypertrophy as assessed by cardiac magnetic resonance imaging and risk of death in cardiac transplant recipients
2010, Journal of Heart and Lung Transplantation
Citation Excerpt :
Our current study substantially extends these data. Cardiac MRI was used to assess LV mass and geometry, and cardiac MRI has been shown to have greater accuracy for these purposes than echocardiography.37 With more accurate assessments of LV volume and wall thickness, we were able to demonstrate that a concentric—and not eccentric phenotype—was associated with adverse outcome.
Although risk factors for left ventricular (LV) hypertrophy in the native heart are well known, as is its association with increased risk of adverse outcomes, such information is poorly defined in heart transplant (HTx) recipients. We determined whether increased LV mass and concentricity (mass/volume) were associated with death in patients after HTx.
Between May 2003 and May 2006, 140 HTx recipients underwent cardiac magnetic resonance imaging (MRI). Clinical characteristics associated with increased LV mass were determined. Cox proportional hazard models were constructed to assess the relationship of LV mass and concentricity with death.
MRIs were acquired a median of 6.0 years after transplant. The top quartile of indexed LV mass and concentricity were 35.8 g/m^2.7 or higher and 1.5 g/ml or higher, respectively. History of rejection (odds ratio [OR], 5.9; 95% confidence interval [CI], 2.1–16.4; p < 0.01), diabetes (OR, 3.3; 95% CI, 1.3–8.2; p = 0.01), and post-transplant year of MRI acquisition (OR, 1.2; 95% CI, 1.1–1.4; p < 0.01) were associated with the top quartile of LV mass in multivariable models. LV mass and concentricity were independently associated with cardiovascular death (hazard risk [HR], 1.11 per g/m;^2.7 HR, 10.1 per g/ml, p ≤ 0.01, respectively). LV concentricity was independently associated with all-cause mortality (HR, 4.4 per g/ml, p < 0.01).
A history of rejection and diabetes are associated with increased LV mass. Increased LV mass, particularly of a concentric phenotype, is an independent risk factor for cardiovascular and all-cause mortality after HTx.
Assessment of left ventricular function with single breath-hold highly accelerated cine MRI combined with guide-point modeling
2010, European Journal of Radiology
Citation Excerpt :
Moreover, cine MRI is considered superior to computed tomography and conventional angiographic volumetric analysis [17–19,23] due to its better spatial resolution, the absence of radiation or other harmful side effects. As a result, cardiac MRI has established as the gold standard for estimation of LV function [2–7]. Till the implementation of SSFP sequences mainly fast low angle shot (FLASH) sequences were used for qualitative and quantitative analyses of LV function [7]; to date, standard 2D cine SSFP sequences are regarded as the standard of reference for volumetric measurements [7].
To prospectively assess the performance of highly accelerated cine MRI in multi-orientations combined with a new guide-point modeling post-processing technique (GPM approach) for assessment of left ventricular (LV) function compared to the standard summation of slices method based on a stack of short axis views (SoS approach).
33 consecutive patients were examined on a 1.5 T scanner with a standard steady state free precession (SSFP) sequence (TR, 3.0 ms; TE, 1.5 m; flip angle (FA), 60°; acceleration factor (AF), 2) analyzed with the SoS method and a highly accelerated, single breath-hold temporal parallel acquisition SSFP sequence (TR, 4.6 ms; TE, 1.1 ms; AF, 3) post-processed with the GPM method. LV function values were measured by two independent readers with different experience in cardiac MRI and compared by using the paired t-test and F-test. Inter- and intraobserver agreements were calculated using Bland–Altman-Plots.
Mean acquisition and post-processing time was significantly shorter with the GPM approach (15 s/3 min versus 360 s/6 min). For all LV function parameters interobserver agreement between the experienced and non-experienced reader was significantly improved when the GPM approach was used. However, end-diastolic and end-systolic volumes were larger for the GPM technique when compared to the SoS method (P < 0.001), whereas ejection fraction estimation yielded equivalent results (P > 0.121). In both readers and for all parameters variances did not differ significantly (P ≥ 0.409) and the two approaches showed an excellent linear correlation (r > 0.951).
Due to its accurate, fast and reproducible assessment of LV function parameters highly accelerated MRI combined with the GPM technique may become the technique of first choice for assessment of LV function in clinical routine.
The Role of Multimodality Cardiac Imaging in the Transplanted Heart
2009, JACC: Cardiovascular Imaging
Citation Excerpt :
These quantitative echocardiographic techniques of regional and global myocardial function show promise to identify subclinical LV dysfunction in a small number of cardiac transplant recipients and need further validation in larger studies. Although many transplant centers use echocardiography to detect cardiac allograft systolic dysfunction in the setting of cardiac rejection, CMR enables imaging throughout the cardiac cycle and provides excellent spatial resolution to accurately measure diastolic and systolic volumes and hence left and right ventricular ejection fractions (24) (Fig. 4). CMR may also be useful in the detection of ACR by its ability to quantitate changes in myocardial mass (25) or more specifically to detect myocardial edema.
Heart transplantation (HT) is an established life-saving treatment option for patients with end-stage heart failure. Despite many advances in the field, the development of acute cellular rejection (ACR) and cardiac allograft vasculopathy (CAV) represent significant causes of 1- and 5-year morbidity and mortality, respectively. The search for noninvasive techniques to assess cardiac allograft function and detect treatable ACR and CAV remains a priority objective for heart transplant professionals. In this review we will: 1) highlight the clinical significance of ACR and CAV in adult cardiac transplant recipients and 2) discuss how different noninvasive imaging modalities (echocardiography, cardiac computed tomography, myocardial perfusion imaging, and cardiac magnetic resonance) have been used in the evaluation of these clinical challenges after HT.

View all citing articles on Scopus

View full text

Clinical Heart TransplantationLeft ventricular function and mass after orthotopic heart transplantation: a comparison of cardiovascular magnetic resonance with echocardiography

Abstract

Method

Results

Conclusion

Section snippets

Patients and methods

Reproducibility of CMR

Discussion

Conclusion

Acknowledgements

Am J Cardiol

Mag Reson Imaging

Am J Cardiol

Acad Radiol

Am J Hypertens

J Am Coll Cardiol

Should echocardiography be performed to assess effects of antihypertensive therapy? Test-retest reliability of echocardiography for measurement of left ventricular mass and function. J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

Am J Cardiol

Am Heart J

Factors influencing the development of hypertension after heart transplantation

J Heart Transplant

Serial echo findings early after heart transplantationevidence for reversible right ventricular dysfunction and myocardial oedema

J Heart Transplant

Echocardiographic profile of the transplanted human heart in clinically well recipients

J Heart Lung Transplant

Serial changes in left ventricular mass of the donor’s heart early after transplantation (abstract)

J Am Coll Cardiol

Assessment of early left ventricular remodelling in orthotopic heart transplant recipients with cine magnetic resonance imagingpotential mechanisms

J Heart Lung Transplant

Comparative value of eight M-mode echocardiographic formulas for determining left ventricular stroke volume

Circulation

Assessment of left ventricular volumes by magnetic resonance in comparison with radionuclide angiography, contrast angiography and echocardiography

Eur Heart J

Estimation of human myocardial mass with MR imaging

Radiology

Clinical Heart Transplantation
Left ventricular function and mass after orthotopic heart transplantation: a comparison of cardiovascular magnetic resonance with echocardiography