European Radiology

, Volume 28, Issue 10, pp 4111–4121 | Cite as

Comprehensive morphologic and functional imaging of heart transplant patients: first experience with dynamic perfusion CT

  • S. Oebel
  • S. Hamada
  • K. Higashigaito
  • J. von Spiczak
  • E. Klotz
  • F. Enseleit
  • R. Hinzpeter
  • F. Ruschitzka
  • R. Manka
  • H. AlkadhiEmail author



We aimed to assess the diagnostic performance of a combined protocol with coronary computed tomography angiography (CCTA) and stress CT perfusion imaging (CTP) in heart transplant patients for comprehensive morphological and functional imaging.


In this prospective study, 13 patients undergoing routine follow-up 8±6 years after heart transplantation underwent CCTA and dynamic adenosine stress CTP using a third-generation dual-source CT scanner, cardiac magnetic resonance (MR) adenosine stress perfusion imaging at 1.5 T, and catheter coronary angiography. In CCTA stenoses >50% luminal diameter narrowing were noted. Myocardial perfusion deficits were documented in CTP and MR. Quantitative myocardial blood flow (MBF) was calculated with CTP. Left ventricular ejection fraction was determined on cardiac MR cine images. Radiation doses of CT were determined.


One of the 13 patients had to be excluded because of severe motion artifacts. CCTA identified three patients with stenosis >50%, which were confirmed with catheter coronary angiography. CTP showed four patients with stress-induced myocardial hypoperfusion, which were confirmed by MR stress perfusion imaging. Quantitative analysis of global MBF showed lower mean values as compared to known reference values (MBF under stress 125.5 ± 34.5 ml/100 ml/min). Average left ventricular ejection fraction was preserved (56 ± 5%).


In heart transplant patients, a comprehensive CT protocol for the assessment of morphology and function including CCTA and CTP showed good concordance to results from MR perfusion imaging and catheter coronary angiography.

Key Points

• Stress CT perfusion imaging enables the detection of myocardial ischemia

• CT myocardial perfusion imaging can be combined with coronary computed tomography angiography

• Combining perfusion and coronary CT imaging is accurate in heart transplant patients

• CT myocardial perfusion imaging can be performed at a reasonable radiation dose


Coronary angiography Multidetector-row computed tomography Magnetic resonance imaging Myocardial perfusion imaging Transplantation 



Beats per minute


Cardiac allograft vasculopathy


Coronary computed tomography angiography


Computed tomography


Computed tomography perfusion




Estimated glomerular filtration rate




Graft rejection


International society of heart and lung transplantation


Left ventricle


Myocardial blood flow


Magnetic resonance


Mechanistic target of rapamycin



The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Hatem Alkadhi.

Conflict of interest

The authors of this manuscript declare relationships with the following companies: Dr. Ernst Klotz, PhD, is physicist of Siemens Healthcare with an expertise in CT perfusion imaging.

Statistics and biometry

One of the authors has significant statistical expertise.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.


• prospective

• case-control study

• performed at one institution


  1. 1.
    Chambers DC, Yusen RD, Cherikh WS et al (2017) The Registry of the International Society for Heart and Lung Transplantation: Thirty-fourth Adult Lung And Heart-Lung Transplantation Report-2017; Focus Theme: Allograft ischemic time. J Heart Lung Transplant. CrossRefGoogle Scholar
  2. 2.
    Costanzo MR, Dipchand A, Starling R et al (2010) The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. J Heart Lung Transplant 29:914–956CrossRefGoogle Scholar
  3. 3.
    Stehlik J, Edwards LB, Kucheryavaya AY et al (2010) The Registry of the International Society for Heart and Lung Transplantation: twenty-seventh official adult heart transplant report--2010. J Heart Lung Transplant 29:1089–1103CrossRefGoogle Scholar
  4. 4.
    Tsutsui H, Ziada KM, Schoenhagen P et al (2001) Lumen loss in transplant coronary artery disease is a biphasic process involving early intimal thickening and late constrictive remodeling: results from a 5-year serial intravascular ultrasound study. Circulation 104:653–657CrossRefGoogle Scholar
  5. 5.
    Valantine HA (2003) Cardiac allograft vasculopathy: central role of endothelial injury leading to transplant “atheroma”. Transplantation 76:891–899CrossRefGoogle Scholar
  6. 6.
    Gao SZ, Alderman EL, Schroeder JS, Silverman JF, Hunt SA (1988) Accelerated coronary vascular disease in the heart transplant patient: coronary arteriographic findings. J Am Coll Cardiol 12:334–340CrossRefGoogle Scholar
  7. 7.
    Rickenbacher PR, Pinto FJ, Chenzbraun A et al (1995) Incidence and severity of transplant coronary artery disease early and up to 15 years after transplantation as detected by intravascular ultrasound. J Am Coll Cardiol 25:171–177CrossRefGoogle Scholar
  8. 8.
    Fearon WF, Nakamura M, Lee DP et al (2003) Simultaneous assessment of fractional and coronary flow reserves in cardiac transplant recipients: Physiologic Investigation for Transplant Arteriopathy (PITA Study). Circulation 108:1605–1610CrossRefGoogle Scholar
  9. 9.
    McDiarmid AK, Plein S, Ross HJ (2016) Emerging imaging techniques after cardiac transplantation. J Heart Lung Transplant 35:1399–1411CrossRefGoogle Scholar
  10. 10.
    Krieghoff C, Barten MJ, Hildebrand L et al (2014) Assessment of sub-clinical acute cellular rejection after heart transplantation: comparison of cardiac magnetic resonance imaging and endomyocardial biopsy. Eur Radiol 24:2360–2371CrossRefGoogle Scholar
  11. 11.
    Taylor AJ, Vaddadi G, Pfluger H et al (2010) Diagnostic performance of multisequential cardiac magnetic resonance imaging in acute cardiac allograft rejection. Eur J Heart Fail 12:45–51CrossRefGoogle Scholar
  12. 12.
    Muehling OM, Wilke NM, Panse P et al (2003) Reduced myocardial perfusion reserve and transmural perfusion gradient in heart transplant arteriopathy assessed by magnetic resonance imaging. J Am Coll Cardiol 42:1054–1060CrossRefGoogle Scholar
  13. 13.
    Rivard AL, Swingen CM, Blake D et al (2007) A comparison of myocardial perfusion and rejection in cardiac transplant patients. Int J Card Imaging 23:575–582CrossRefGoogle Scholar
  14. 14.
    Ponikowski P, Voors AA, Anker SD et al (2016) 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 18:891–975CrossRefGoogle Scholar
  15. 15.
    European Society of C, European Heart Rhythm A, Brignole M et al (2013) 2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy: the task force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Europace 15:1070–1118CrossRefGoogle Scholar
  16. 16.
    Wever-Pinzon O, Romero J, Kelesidis I et al (2014) Coronary computed tomography angiography for the detection of cardiac allograft vasculopathy: a meta-analysis of prospective trials. J Am Coll Cardiol 63:1992–2004CrossRefGoogle Scholar
  17. 17.
    Schepis T, Achenbach S, Weyand M et al (2009) Comparison of dual source computed tomography versus intravascular ultrasound for evaluation of coronary arteries at least one year after cardiac transplantation. Am J Cardiol 104:1351–1356CrossRefGoogle Scholar
  18. 18.
    Takx RAP, Celeng C, Schoepf UJ (2017) CT myocardial perfusion imaging: ready for prime time? Eur Radiol. CrossRefGoogle Scholar
  19. 19.
    Rossi A, Dharampal A, Wragg A et al (2014) Diagnostic performance of hyperaemic myocardial blood flow index obtained by dynamic computed tomography: does it predict functionally significant coronary lesions? Eur Heart J Cardiovasc Imaging 15:85–94CrossRefGoogle Scholar
  20. 20.
    Austen WG, Edwards JE, Frye RL et al (1975) A reporting system on patients evaluated for coronary artery disease. Report of the Ad Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery, American Heart Association. Circulation 51:5–40CrossRefGoogle Scholar
  21. 21.
    Cerqueira MD, Weissman NJ, Dilsizian V et al (2002) Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation 105:539–542CrossRefGoogle Scholar
  22. 22.
    Rossi A, Wragg A, Klotz E et al (2017) Dynamic computed tomography myocardial perfusion imaging: comparison of clinical analysis methods for the detection of vessel-specific ischemia. Circ Cardiovasc Imaging.
  23. 23.
    Vitanis V, Manka R, Giese D et al (2011) High resolution three-dimensional cardiac perfusion imaging using compartment-based k-t principal component analysis. Magn Reson Med 65:575–587CrossRefGoogle Scholar
  24. 24.
    Manka R, Wissmann L, Gebker R et al (2015) Multicenter evaluation of dynamic three-dimensional magnetic resonance myocardial perfusion imaging for the detection of coronary artery disease defined by fractional flow reserve. Circ Cardiovasc Imaging 8Google Scholar
  25. 25.
    Mehra MR, Crespo-Leiro MG, Dipchand A et al (2010) International Society for Heart and Lung Transplantation working formulation of a standardized nomenclature for cardiac allograft vasculopathy-2010. J Heart Lung Transplant 29:717–727CrossRefGoogle Scholar
  26. 26.
    Trattner S, Halliburton S, Thompson CM et al (2018) Cardiac-Specific Conversion Factors to Estimate Radiation Effective Dose From Dose-Length Product in Computed Tomography. JACC Cardiovasc Imaging 11:64–74CrossRefGoogle Scholar
  27. 27.
    Ho KT, Ong HY, Tan G, Yong QW (2015) Dynamic CT myocardial perfusion measurements of resting and hyperaemic blood flow in low-risk subjects with 128-slice dual-source CT. Eur Heart J Cardiovasc Imaging 16:300–306CrossRefGoogle Scholar
  28. 28.
    Meinel FG, Ebersberger U, Schoepf UJ et al (2014) Global quantification of left ventricular myocardial perfusion at dynamic CT: feasibility in a multicenter patient population. AJR Am J Roentgenol 203:W174–W180CrossRefGoogle Scholar
  29. 29.
    Bilchick KC, Henrikson CA, Skojec D, Kasper EK, Blumenthal RS (2004) Treatment of hyperlipidemia in cardiac transplant recipients. Am Heart J 148:200–210CrossRefGoogle Scholar
  30. 30.
    Kobashigawa JA, Moriguchi JD, Laks H et al (2005) Ten-year follow-up of a randomized trial of pravastatin in heart transplant patients. J Heart Lung Transplant 24:1736–1740CrossRefGoogle Scholar
  31. 31.
    Luechinger R, Zeijlemaker VA, Pedersen EM et al (2005) In vivo heating of pacemaker leads during magnetic resonance imaging. Eur Heart J 26:376–383 discussion 325-377CrossRefGoogle Scholar
  32. 32.
    Danad I, Szymonifka J, Schulman-Marcus J, Min JK (2016) Static and dynamic assessment of myocardial perfusion by computed tomography. Eur Heart J Cardiovasc Imaging 17:836–844CrossRefGoogle Scholar
  33. 33.
    Dey D, Slomka PJ, Berman DS (2014) Achieving very-low-dose radiation exposure in cardiac computed tomography, single-photon emission computed tomography, and positron emission tomography. Circ Cardiovasc Imaging 7:723–734CrossRefGoogle Scholar
  34. 34.
    Cademartiri F, Seitun S, Clemente A et al (2017) Myocardial blood flow quantification for evaluation of coronary artery disease by computed tomography. Cardiovasc Diagn Ther 7:129–150CrossRefGoogle Scholar
  35. 35.
    Kono AK, Coenen A, Lubbers M et al (2014) Relative myocardial blood flow by dynamic computed tomographic perfusion imaging predicts hemodynamic significance of coronary stenosis better than absolute blood flow. Invest Radiol 49:801–807CrossRefGoogle Scholar
  36. 36.
    Pampaloni MH, Shrestha UM, Sciammarella M, Seo Y, Gullberg GT, Botvinick EH (2017) Noninvasive PET quantitative myocardial blood flow with regadenoson for assessing cardiac allograft vasculopathy in orthotopic heart transplantation patients. J Nucl Cardiol. CrossRefGoogle Scholar
  37. 37.
    Reid AB, Waldron N, Schmitt M, Miller CA (2015) The Value of Cardiovascular Magnetic Resonance in Heart Transplant Patients. Curr Cardiol Rep 17:612CrossRefGoogle Scholar
  38. 38.
    Chevance V, Damy T, Tacher V et al (2017) Myocardial iodine concentration measurement using dual-energy computed tomography for the diagnosis of cardiac amyloidosis: a pilot study. Eur Radiol. CrossRefGoogle Scholar
  39. 39.
    Pelgrim GJ, van Hamersvelt RW, Willemink MJ et al (2017) Accuracy of iodine quantification using dual energy CT in latest generation dual source and dual layer CT. Eur Radiol 27:3904–3912CrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  1. 1.Institute of Diagnostic and Interventional Radiology, University Hospital ZurichUniversity of ZurichZurichSwitzerland
  2. 2.Department of Cardiology, University Hospital ZurichUniversity of ZurichZurichSwitzerland
  3. 3.Siemens Healthineers, Computed TomographyForchheimGermany

Personalised recommendations