What are reasonable alternatives to invasive angiography for CAV surveillance in patients who are a few years out from cardiac transplant with impaired renal function?

In our practice, we move to PET-CT on Year 3 if the prior 2 angiograms with IVUS did not show accelerating disease. The issue with CAV is that there is not much to do about it reactively. The best you can do, is switch to an mTORi regimen early and optimize lipids. IVUS is useful for that reason. Beyond that, PET-CT is more sensitive for microvascular involvement which is more prognostic (REFs below) for mortality. [Yang et al., PMID 27143679, Ahn et al., PMID 34665224] In our program, any abnormality on PET-CT with warrant follow up with angiography and IVUS.

Alternatively, in low risk patients > 5 years out (those with normal caths and PETs) can probably have dobutamine stress echocardiograms in order to save them the radiation. DSE, howe...

We often use cardiac PETs in our post transplant patients after year 5, as long as they have CAV 0 or 1 in the first 5 years. The cardiac PETs must be read differently than a typical cardiac PET but based on the results, we can then talk to the patient if angiography is worth the risk or avoid using contrast all together. See articles below:

• Feher & Miller, PMID 36279035