Background: Cardiovascular Magnetic Resonance (CMR) is the gold standard technique for function evaluation and non-invasive tissue characterization of the myocardium, and it is entering heavily into the management of heart-transplant (HT) patients in whom endomyocardial biopsy (EMB) is the reference technique, despite its invasiveness and sampling issues. Objectives:to compare EMB and CMR findings in HT population in the real clinical context of our Institute and to assess CMR and EMB diagnostic and prognostic value. Materials and methods: We prospectively evaluated HT patients who underwent CMR (Siemens Magnetom-Avanto Fit 1.5T) between October-2021 and Dicember-2024 as follow-up or suspected rejection. Patients who performed a EMB within 90 days from CMR were enrolled and histological reports were collected, as well as clinical and instrumental data. EMB results were compared with CMR tissue characterization obtained from traditional (cineSSFP for function, TIRM T2 for oedema, T1w fast GRE for perfusion and PSIR for late gadolinium enhancement, LGE) and advanced sequences (cineSSFP for strain analysis, MOLLI for T1 mapping and extracellular volume, ECV, and T2p-SSFP for T2 mapping). CMR rejection was defined as the presence of oedema (positive TIRM T2 or T2 mapping by segmental approach). The correlation between CMR findings and cardiac disease (heart failure or EMB rejection) was evaluated. A clinical follow-up was closed in Dec-2024 to assess the development of cardiovascular events defined as hospitalization for cardiac causes and EMB rejection.To assess the normality of the variables, the Shapiro-Wilk test was used. To compare continuous variables, the T or Mann-Whitney test was used and for categorical variables, the χ² or McNemar test was used. P<0.05 was considered statistically significant. The agreement between CMR and EMB was assessed with Cohen’s k test. On the basis of the independent variables examined, a binomial logistic regression model was used to determine the probability of the occurrence of cardiac disease. Results:Sixteen patients (10 men, 53±18 years) were included. The mean interval between HT and CMR was 46±98 months, while between EMB and CMR was 25±33 days. The follow up time was 23±16 months. CMR showed myocardial oedema in 10 patients (62.5%), 5 with LGE in the same segments (31.25%); 3 out of 10 patients with CMR oedema (18.75%) showed a negative EMB. Both CMR and EMB were positive for rejection in 7 (43.7%) and negative in 6 (37.5%). Ischemic or non-ischemic fibrosis was found in 8 patients (50%), while EMB showed fibrosis in 3 cases (18.75%). No statistically significant differences were found in identifying rejection and fibrosis between the two methods, that showed a good agreement in identifying rejection (κ=0.636) with a positive predictive value of 70% and a negative predictive value of 100% considering the EMB as gold standard. Ten patients (62.5%) showed cardiac disease at the time of CMR: 1 (6.25%) had heart failure, and 9 (56.25%) had EMB rejection, CMR findings of oedema turned out to be indicators of cardiac disease (p<0.05). Accordingly, the binomial logistic regression model identified the presence of rejection at CMR as a significant predictor of cardiac disease at the time of CMR (p=0.012, AUC 0.867). Two patients developed cardiac events (hospitalization for rejection) during the follow up and both CMR and EMB were not predictive (p>0.05). Conclusions:Based on our data advanced CMR seems to be a non-invasive effective tool for HT patients monitoring, identifying an early cardiac damage even when EMB is negative, for tailoring the therapy.Conversely, it does not fail in detecting myocardial alterations when the EMB is positive for rejection.Both CMR and EMB were not predictive for cardiac events probably due to the events low rate at the short-term follow-up.Further multicentric studies on larger population with longer follow-up are recommended.
Background:La Risonanza Magnetica Cardiovascolare (RMC) è la tecnica di riferimento per la valutazione di funzione e caratterizzazione non invasiva del miocardio ed è sempre più utilizzata nella gestione dei pazienti (pz) sottoposti a trapianto di cuore (TC), dove la biopsia endomiocardica (BEM) è la tecnica di riferimento, nonostante l’invasività e i problemi di campionamento. Obiettivi:Confrontare i risultati BEM e RMC nella popolazione TC nel contesto clinico del nostro Istituto e valutare il valore diagnostico e prognostico di RMC e BEM. Materiali e metodi:Valutazione prospettica dei pz TC sottoposti a RMC (Siemens Magnetom-Avanto Fit 1.5T) tra ott-2021 e dic-2024, per follow-up o sospetto rigetto. Sono stati arruolati i pz con BEM entro 90 giorni da RMC e raccolti referti istologici, dati clinici, strumentali. I risultati BEM sono stati confrontati con la caratterizzazione tissutale ottenuta dalla RMC tramite sequenze tradizionali (cineSSFP per funzione, TIRM T2 per edema, sequenze T1w fast GRE per perfusione e PSIR per LGE) e sequenze avanzate (cineSSFP per lo strain, MOLLI per T1mapping e volume extracellulare, ECV, e T2p-SSFP per T2mapping). Il rigetto RMC è stato definito dalla presenza di edema (TIRM T2 positive o T2mapping con approccio segmentale). È stata valutata la correlazione tra i reperti RMC e patologia cardiaca (scompenso cardiaco o rigetto BEM). Un follow-up clinico è stato concluso a dicembre 2024 per valutare lo sviluppo di eventi cardiovascolari definiti come ricovero per cause cardiache e rigetto BEM. Abbiamo utilizzato il test di Shapiro-Wilk, il test T o Mann-Whitney, il test χ² o McNemar, con un valore p <0,05 statisticamente significativo. L'accordo tra RMC e BEM è stato valutato con il test k di Cohen. Un modello di regressione logistica binomiale è stato utilizzato per determinare la probabilità di insorgenza di patologia cardiaca. Risultati:Sono stati inclusi 16 pz (10 uomini, 53±18 anni). L'intervallo medio tra HT e RMC è stato di 46±98 mesi, tra BEM e RMC di 25±33 giorni. La durata del follow-up è stata di 23±16 mesi. La RMC mostrava edema miocardico in 10 pz (62,5%), di cui 5 con LGE negli stessi segmenti (31,25%); 3 dei 10 pz con edema RMC (18,75%) mostravano BEM negativa. Sia RMC che BEM erano positive per rigetto in 7 pz (43,7%) e negative in 6 casi (37,5%). La fibrosi ischemica o non ischemica era presente in 8 pz (50%), mentre la BEM mostrava fibrosi in 3 (18,75%). Non sono state trovate differenze statisticamente significative nell'identificazione di rigetto e fibrosi tra i due metodi, che hanno mostrato una buona concordanza nell'identificare il rigetto (κ=0,636) con un valore predittivo positivo del 70% e un valore predittivo negativo del 100%, considerando la BEM come gold standard.Dieci pz (62,5%) hanno mostrato patologia cardiaca al momento della RMC: 1 pz (6,25%) con insufficienza cardiaca e 9 pz (56,25%) con rigetto BEM; i risultati di RMC con edema si sono rivelati indicatori di patologia cardiaca (p<0,05).Di conseguenza, il modello di regressione logistica binomiale ha identificato la presenza di rigetto alla RMC come un predittore significativo di patologia cardiaca al momento della RMC (p=0,012, AUC 0,867). Due pz hanno sviluppato eventi cardiaci (ricovero per rigetto) durante il follow-up e sia la RMC che la BEM non sono stati predittive (p>0,05). Conclusioni: Sulla base dei nostri dati, la RMC avanzata sembra essere uno strumento non invasivo efficace per il monitoraggio dei pz TC, identificando un danno cardiaco precoce anche quando la BEM è negativa, per personalizzare la terapia.Al contrario, non fallisce nel rilevare alterazioni miocardiche quando la BEM è positiva per rigetto.Sia la RMC che la BEM non sono stati predittive per eventi cardiaci, probabilmente a causa del basso tasso di eventi nel follow-up a breve termine.Si raccomandano ulteriori studi multicentrici su popolazioni più ampie con follow-up più lungo.
TESTA A TESTA: CONFRONTO TRA RISONANZA MAGNETICA CARDIOVASCOLARE AVANZATA E BIOPSIA ENDOMIOCARDICA NEL TRAPIANTO DI CUORE
PERAZZOLO, ANNA
2022/2023
Abstract
Background: Cardiovascular Magnetic Resonance (CMR) is the gold standard technique for function evaluation and non-invasive tissue characterization of the myocardium, and it is entering heavily into the management of heart-transplant (HT) patients in whom endomyocardial biopsy (EMB) is the reference technique, despite its invasiveness and sampling issues. Objectives:to compare EMB and CMR findings in HT population in the real clinical context of our Institute and to assess CMR and EMB diagnostic and prognostic value. Materials and methods: We prospectively evaluated HT patients who underwent CMR (Siemens Magnetom-Avanto Fit 1.5T) between October-2021 and Dicember-2024 as follow-up or suspected rejection. Patients who performed a EMB within 90 days from CMR were enrolled and histological reports were collected, as well as clinical and instrumental data. EMB results were compared with CMR tissue characterization obtained from traditional (cineSSFP for function, TIRM T2 for oedema, T1w fast GRE for perfusion and PSIR for late gadolinium enhancement, LGE) and advanced sequences (cineSSFP for strain analysis, MOLLI for T1 mapping and extracellular volume, ECV, and T2p-SSFP for T2 mapping). CMR rejection was defined as the presence of oedema (positive TIRM T2 or T2 mapping by segmental approach). The correlation between CMR findings and cardiac disease (heart failure or EMB rejection) was evaluated. A clinical follow-up was closed in Dec-2024 to assess the development of cardiovascular events defined as hospitalization for cardiac causes and EMB rejection.To assess the normality of the variables, the Shapiro-Wilk test was used. To compare continuous variables, the T or Mann-Whitney test was used and for categorical variables, the χ² or McNemar test was used. P<0.05 was considered statistically significant. The agreement between CMR and EMB was assessed with Cohen’s k test. On the basis of the independent variables examined, a binomial logistic regression model was used to determine the probability of the occurrence of cardiac disease. Results:Sixteen patients (10 men, 53±18 years) were included. The mean interval between HT and CMR was 46±98 months, while between EMB and CMR was 25±33 days. The follow up time was 23±16 months. CMR showed myocardial oedema in 10 patients (62.5%), 5 with LGE in the same segments (31.25%); 3 out of 10 patients with CMR oedema (18.75%) showed a negative EMB. Both CMR and EMB were positive for rejection in 7 (43.7%) and negative in 6 (37.5%). Ischemic or non-ischemic fibrosis was found in 8 patients (50%), while EMB showed fibrosis in 3 cases (18.75%). No statistically significant differences were found in identifying rejection and fibrosis between the two methods, that showed a good agreement in identifying rejection (κ=0.636) with a positive predictive value of 70% and a negative predictive value of 100% considering the EMB as gold standard. Ten patients (62.5%) showed cardiac disease at the time of CMR: 1 (6.25%) had heart failure, and 9 (56.25%) had EMB rejection, CMR findings of oedema turned out to be indicators of cardiac disease (p<0.05). Accordingly, the binomial logistic regression model identified the presence of rejection at CMR as a significant predictor of cardiac disease at the time of CMR (p=0.012, AUC 0.867). Two patients developed cardiac events (hospitalization for rejection) during the follow up and both CMR and EMB were not predictive (p>0.05). Conclusions:Based on our data advanced CMR seems to be a non-invasive effective tool for HT patients monitoring, identifying an early cardiac damage even when EMB is negative, for tailoring the therapy.Conversely, it does not fail in detecting myocardial alterations when the EMB is positive for rejection.Both CMR and EMB were not predictive for cardiac events probably due to the events low rate at the short-term follow-up.Further multicentric studies on larger population with longer follow-up are recommended.File | Dimensione | Formato | |
---|---|---|---|
Tesi_PerazzoloAnna.pdf
accesso riservato
Dimensione
2.49 MB
Formato
Adobe PDF
|
2.49 MB | Adobe PDF |
The text of this website © Università degli studi di Padova. Full Text are published under a non-exclusive license. Metadata are under a CC0 License
https://hdl.handle.net/20.500.12608/82664