Diagnosis of cardiac allograft vasculopathy Challenges and opportunities

Cardiac allograft vasculopathy (CAV) is one of the most common long-term complications in patients following heart transplantation. Because of its irreversible nature, early detection is essential to impact progression. Thus, imaging techniques play a crucial role in the diagnosis and subsequent treatment. Major advancements in imaging and analysis are required to overcome the limitations of current techniques. Coronary angiography which is the standard method, presents low sensitivity in detection, especially at an early stage. Intravascular ultrasonography is a more reliable alternative but is limited to the epicardial vessels. Novel non-invasive techniques, such as stress echocardiography and nuclear imaging, have been introduced but not without limitations. Here, we review various imaging methods and associated analyses to improve diagnostic predictions. We discuss recent advances in the diagnosis of coronary artery disease and their potential translation in the diagnosis of CAV. Additionally, we present potential biomarkers that have been identified for CAV. Finally, we provide a discussion on microvessels with novel anticoagulant properties that are mostly identified in patients with severe CAV.