Intravascular ultrasound–guided selection for early noninvasive cardiac allograft vasculopathy screening in heart transplant recipients

Background Noninvasive screening for cardiac allograft vasculopathy (CAV) instead of invasive coronary angiography (ICA) within the first 3 to 5 years after heart transplantation (HTx) is controversial. We evaluated a strategy of intravascular ultrasound (IVUS)–guided conversion to early noninvasive screening post‐HTx. Methods A single‐center study of 103 consecutive HTx recipients from 2008 to 2018 undergoing ICA at 1 year post‐HTx. Of 88 patients with normal 1‐year ICA, sixty‐six patients underwent IVUS examination for risk stratification by maximal intimal thickness (MIT) into (i) low‐risk group (MIT < 0.5 mm) ( n  = 41, 62%) followed noninvasively versus (ii) high‐risk group (MIT ≥ 0.5 mm) ( n  = 25, 38%) followed with yearly ICA. Both groups underwent ICA at year 5 post‐HTx. We evaluated a combined endpoint of angiographic CAV and death at 5‐year follow‐up post‐HTx. Results Median (IQR) age was 51 (33–60) years, and 62% were male. Follow‐up was 1443 (1125–1456) days. Survival free from angiographic CAV (Kaplan‐Meier) differed significantly between groups (log‐rank p  < .0001). A subgroup of 27 patients completed ICA at year 5, and the proportion of angiographic CAV was significantly lower in low‐risk patients ( p  < .0001). Conclusion IVUS‐guided selection for early noninvasive CAV screening appears to be safe and holds promise as a novel strategy for early risk stratification and CAV surveillance post‐HTx.