Cardiovascular magnetic resonance feature tracking for rejection surveillance after cardiac transplantation

Jim Pouliopoulos; Muhummad Imran; Chris Anthony; Cassia Kessler; Kirsten Moffat; Min Ru Qiu; Christian Stehning; Valentina Puntmann; Sanjay Prasad; Robert M Graham; Jane McCrohon; Cameron Holloway; Eugene Kotlyar; Kavitha Muthiah; Anne M Keogh; Christopher S Hayward; Peter S Macdonald; Andrew Jabbour

doi:10.1016/j.jocmr.2025.102675

Cardiovascular magnetic resonance feature tracking for rejection surveillance after cardiac transplantation

J Cardiovasc Magn Reson. 2025 Dec 24;28(1):102675. doi: 10.1016/j.jocmr.2025.102675. Online ahead of print.

Authors

Jim Pouliopoulos¹, Muhummad Imran², Chris Anthony³, Cassia Kessler⁴, Kirsten Moffat⁵, Min Ru Qiu⁶, Christian Stehning⁷, Valentina Puntmann⁸, Sanjay Prasad⁹, Robert M Graham¹⁰, Jane McCrohon⁶, Cameron Holloway⁶, Eugene Kotlyar⁶, Kavitha Muthiah⁶, Anne M Keogh¹¹, Christopher S Hayward¹¹, Peter S Macdonald¹, Andrew Jabbour¹²

Affiliations

¹ Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia; UNSW, School of Clinical Medicine, Sydney, Australia.
² Fairfield Hospital, Fairfield, Australia.
³ The Alfred Health, Melbourne, Australia; Monash Alfred Baker Centre for Cardiovascular Research, Melbourne, Australia.
⁴ Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Medical Imaging Department, St. Vincent's Hospital, Sydney, Australia; UNSW, School of Clinical Medicine, Sydney, Australia.
⁵ Medical Imaging Department, St. Vincent's Hospital, Sydney, Australia.
⁶ Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia.
⁷ Philips GmbH Innovative Technologies, Hamburg, Germany.
⁸ Institute for Experimental and Translational Cardiovascular Imaging, Goethe University Hospital, Frankfurt, Germany.
⁹ CMR, Royal Brompton Hospital, Imperial College London, London, United Kingdom.
¹⁰ Victor Chang Cardiac Research Institute, Sydney, Australia; UNSW, School of Clinical Medicine, Sydney, Australia.
¹¹ Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; UNSW, School of Clinical Medicine, Sydney, Australia.
¹² Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia; UNSW, School of Clinical Medicine, Sydney, Australia. Electronic address: Andrew.Jabbour@svha.org.au.

Abstract

Background: Endomyocardial biopsy (EMB) is the standard invasive method for monitoring acute cardiac allograft rejection (ACAR); however, non-invasive alternatives are increasingly proving to be dependable.

Objectives: We aimed to identify and validate dependable cardiovascular magnetic resonance (CMR) strain indices for ACAR detection.

Methods: We analyzed 160 CMR scans, including long- and short-axis cines, as well as T1/T2 maps from 54 transplant recipients. Uniparametric and multiparametric models integrating left ventricular strain metrics and tissue characteristics were developed to classify histological rejection grades (0, 1 R, ≥2 R) and evaluate therapeutic response.

Results: Regression analysis using generalized linear mixed-models identified significant differences between rejection groups, with global radial strain (GRS) (z-value = 3.1, p = 0.002) and global circumferential strain (GCS) (z-value = 2.5 p<0.008) outperforming global longitudinal strain (GLS) in discriminating ≥2 R from 1 R rejection. Diagnostic performance for detecting ≥2 R rejection was excellent, particularly for GCS (AUC = 0.852, negative predictive value [NPV] = 98.3%) and GRS (AUC = 0.826, NPV = 95.8% (95.8/100)), with enhanced accuracy in the anterolateral mid-basal segments (AUC>0.886, NPV>97.9%). Strain metrics effectively monitored recovery post-therapy for ≥2 R rejection, showing significant improvements (GRS Δ24.5±7.1%, GCS Δ15.9±4.6%, GLS Δ27.4±11.8%, all p<0.02). Furthermore, as strained-based detection of ≥2 R rejection correlated with increases in edema detected using T1/T2 mapping (all p<0.001), integrating strain with T1/T2 mapping significantly enhanced diagnostic accuracy, with T2+GRS (AUC = 0.931, NPV = 98.2) and T1+T2+GCS (AUC = 0.943, NPV = 97.5) as the most effective models.

Conclusion: Segmental CMR strain analysis demonstrates excellent diagnostic accuracy and negative predictive value for detecting high-grade ACAR and monitoring post-therapy recovery. This non-invasive approach, particularly when integrated with multiparametric models combining global strain and tissue mapping, has the potential to reduce reliance on invasive EMBs for ACAR surveillance in cardiac transplant recipients.

Keywords: Acute cardiac allograft rejection; Cardiac magnetic resonance imaging; Heart transplantation; Immunosuppression; Surveillance.