Comprehensive Cardiac Structure-Function Analysis in Heart Transplantation

心脏移植中全面的心脏结构功能分析

• 批准号: 8630169
• 负责人: James Carr
• 金额: $ 46.74万
• 依托单位: NORTHWESTERN UNIVERSITY AT CHICAGO
• 依托单位国家: 美国
• 财政年份: 2014
• 资助国家: 美国
• 起止时间: 2014-02-04 至 2019-01-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8630169
• 关键词: Acute; Allografting; Ambulatory Care Facilities; Angiography; Area; Biopsy; Blood Vessels; Cardiac; Caring; Catheters; Cause of Death; Clinical; Clinical Research; Coronary; Coronary Angiography; Cost Effectiveness Analysis; Coupled; Data; Decision Modeling; Decision Trees; Detection; Diagnostic; Diagnostic tests; Diffuse; Disease; Early Diagnosis; Echocardiography; Edema; Evaluation; Event; Fibrosis; Functional disorder; Goals; Gold; Healthcare; Heart; Heart Transplantation; Image; Impairment; Individual; Left; Life; Longitudinal Studies; Magnetic Resonance Imaging; Maps; Modality; Modeling; Monitor; Myocardial; Nature; Operative Surgical Procedures; Outcome; Patient Monitoring; Patients; Perfusion; Phase; Procedures; Protocols documentation; Quality of life; Reference Standards; Resources; Risk; Risk Factors; Risk Marker; Sampling Errors; Sensitivity and Specificity; Structure; Techniques; Testing; Thick; Time; Tissues; Transplant Recipients; Transplantation; Ultrasonography; Vascular Diseases; Visit; base; comparative; cost; cost effectiveness; extracellular; follow-up; heart allograft; imaging modality; improved; markov model; mortality; non-invasive imaging; novel; public health relevance; two-arm study

SUMMARY / ABSTRACT Heart transplant (Tx) surgery is a well-established life-saving procedure, but is associated with post- interventional risks such as acute cardiac rejection (ACR) which is one of the leading causes of death in the first year after transplant. Beyond the first year, cardiac allograft vasculopathy (CAV) is the single greatest risk factor for 5-year mortality. Monitoring the patient for post-transplant events is thus paramount. The standard monitoring strategy, however, relies on frequent (12-16 monitoring nodes during year 1 alone) invasive and costly procedures including endomyocardial biopsies (EMB) and catheter angiography. Since EMB and catheter angiography have limited sensitivity due to sampling errors (ACR) or the diffuse nature of the disease (CAV), a reliable non-invasive alternative for the early detection of ACR and CAV would be desirable to reduce the need for invasive procedures, improve sensitivity, and reduce cost. We have recently developed and applied cardiac MRI techniques for the non-invasive assessment of myocardial edema (T2-mapping), diffuse fibrosis (pre- and post-contrast T1-mapping), myocardial velocities (tissue phase mapping), and microvascular quantitative perfusion. We have shown that these techniques can identify distinct regional structural and functional alterations in the heart that correlate with the status of the allograft. Based on these findings, a detailed cost-effective analysis using Markov modeling and decision tree analysis has demonstrated that cardiac MR has tremendous potential to reduce monitoring costs by 40-50% during the first year after Tx alone. This proposal builds on these promising findings and our aim is to develop an new 15-minute structure-function cardiac MRI protocol for the improved detection regional abnormalities associated with ACR (edema, fibrosis, dysfunction) and CAV (perfusion, dysfunction). Integration of MRI with echocardiography and intravascular Ultrasound (IVUS) will provide unique multi-modality assessment of the allograft. The application in a longitudinal clinical study coupled with state-of-the-art cost-effectiveness analysis will allow redefining the most effective post-Tx mixed monitoring strategy. The aim is to to help clinicians identify the optimal mixed monitoring strategy, i.e. the optimal combination of multi-modality imaging (structure-function MRI, echo, IVUS) and invasive procedures (EMB, catheter angiography) which provide best outcome (quality adjusted life days) and lowest cost for the individual cardiac transplant patient.

总结/摘要 心脏移植（Tx）手术是一种行之有效的挽救生命的手术，但与术后并发症有关。 介入风险，如急性心脏排斥反应（ACR），这是死亡的主要原因之一， 移植后第一年超过第一年，心脏移植物血管病变（CAV）是单一的最大风险 5年死亡率的因素。因此，监测患者的移植后事件至关重要。标准 然而，监测策略依赖于频繁的（仅在第1年期间就有12-16个监测节点）侵入性和 昂贵的手术，包括肌内膜活检（EMB）和导管血管造影术。由于教统局及 由于采样误差（ACR）或疾病的弥漫性，导管血管造影术的灵敏度有限 (CAV)，一个可靠的非侵入性的替代早期检测ACR和CAV将是可取的，以减少 对侵入性手术的需求，提高灵敏度，并降低成本。 我们最近开发并应用了心脏MRI技术，用于非侵入性评估 心肌水肿（T2标测）、弥漫性纤维化（造影前后T1标测）、心肌速度 （组织相位映射）和微血管定量灌注。我们已经证明，这些技术可以 识别与心脏状态相关的心脏中不同的区域结构和功能改变， 同种异体移植在此基础上，利用马尔可夫模型和决策树进行了详细的成本效益分析， 分析表明，心脏MR具有将监测成本降低40-50%的巨大潜力 在单独Tx后的第一年。 这项建议建立在这些有希望的发现，我们的目标是开发一个新的15分钟的结构-功能 心脏MRI方案用于改善与ACR相关的区域异常（水肿，纤维化， 功能障碍）和CAV（灌注，功能障碍）。MRI与超声心动图和血管内超声心动图的整合 超声（IVUS）将提供同种异体移植物的独特多模态评估。在A中的应用 纵向临床研究加上最先进的成本效益分析将允许重新定义最 有效的Tx后混合监测策略。其目的是帮助临床医生确定最佳的混合 监测策略，即多模态成像（结构-功能MRI、回波、IVUS）的最佳组合 和侵入性手术（EMB、导管血管造影），可提供最佳结局（质量调整生命日） 和最低的成本。