The use of multimodality imaging in heart transplant recipients: a case series

Background Acute cardiac allograft rejection and cardiac allograft vasculopathy are among the most common and dreaded complications occurring after successful heart transplantation and mandate lifelong monitoring. Non-invasive cardiac imaging with cardiac computed tomography (CCT) and cardiovascular magnetic resonance (CMR) has the potential to reduce the number of invasive exams needed with patient and economic benefits. We present our experience with these imaging techniques in the care of heart transplant recipients. Case summary The first case is a 48-year-old man diagnosed with severe cardiac allograft vasculopathy and subacute asymptomatic anterior myocardial infarction with no residual viability at CMR, where CCT demonstrated complete recanalization of an occluded left anterior descending artery after intensified immunosuppressive therapy. The second case is a 57-year-old man presenting with cardiac arrest due to coronary artery spasm that caused transitory regional wall motion abnormalities subsequently documented with CMR and successfully treated with medical and interventional therapy, owing to the presence of a functionally-significant coronary stenosis possibly triggering vasospasm. The third case is a 69-year-old man hospitalized for acute allograft rejection and severe biventricular dysfunction where CMR was key in managing immunosuppression intensification, alongside endomyocardial biopsy, with complete normalization of biventricular function. Discussion The role of CCT is growing, representing a valid alternative to invasive coronary angiography for screening of cardiac allograft vasculopathy. Cardiovascular magnetic resonance, on the other hand, with the capability to non-invasively characterize myocardial tissue, represents a promising tool in the management of acute cardiac allograft rejection. Further evidence is awaited to validate these techniques in contemporary clinical practice.