Non-invasive multimodality imaging for the evaluation of clinically suspected late cardiac allograft rejection with negative biopsy: a case report
Year: 2026
Type: article
Study design: Case Report
Abstract: Endomyocardial biopsy (EMB), the reference standard for the assessment of cardiac allograft rejection, is invasive and may be limited by sampling error. This case illustrates the potential role of multimodality non-invasive imaging in the evaluation of clinically suspected rejection when EMB findings are negative despite persistent clinical concern. A 55-year-old woman presented with severe dyspnea and end-organ dysfunction approximately 21 years after orthotopic heart transplantation. Serial echocardiography demonstrated progressive biatrial enlargement, restrictive filling physiology, elevated filling pressures, and impaired global longitudinal strain (GLS) despite a preserved left ventricular ejection fraction of 60%. EMB showed no acute cellular rejection (Grade 0R). Multiparametric cardiac magnetic resonance (CMR) demonstrated an elevated mean global myocardial T2 relaxation time of 69 ms across all available myocardial segments. Because of artifact affecting the lateral wall, native T1 mapping was measured using a septal region of interest and showed an elevated T1 value of approximately 1090 ms. The extracellular volume (ECV) fraction was 42%, and two focal areas of near-transmural late gadolinium enhancement were identified in the anterior left ventricular wall. These findings provided supportive evidence of myocardial injury in the context of clinically suspected graft dysfunction but were not specific for cardiac allograft rejection. Immunosuppressive therapy was intensified with anti-thymocyte globulin and corticosteroids, the mycophenolate mofetil dose was increased, and guideline-directed heart-failure therapy was concurrently optimized. The patient demonstrated marked clinical improvement from NYHA functional class IV to I, accompanied by improvement in end-organ function and sustained symptomatic recovery at one-year follow-up. In long-term heart transplant recipients with suspected rejection and negative EMB findings, an integrated multimodality approach, with echocardiography providing functional and hemodynamic assessment and multiparametric CMR providing advanced tissue characterization, may support timely clinical decision-making when interpreted together with clinical, laboratory, histopathological, and therapeutic-response data. Not applicable. Endomyocardial biopsy (EMB) may be falsely negative in cardiac allograft rejection because of sampling error, creating a challenging diagnostic discrepancy in patients with persistent clinical suspicion. Serial echocardiographic findings, including progressive biatrial enlargement, restrictive diastolic physiology, elevated filling pressures, and reduced global longitudinal strain (GLS) despite preserved LVEF, may serve as early warning signs of occult graft dysfunction. Multiparametric cardiac magnetic resonance (CMR) demonstrated abnormal tissue-characterization findings, including prolonged T2, elevated native T1, and increased extracellular volume; however, these abnormalities are not specific for rejection. CMR findings, interpreted together with the clinical, echocardiographic, laboratory, histopathological, and exclusionary findings, contributed to the multidisciplinary decision to intensify immunosuppression, followed by marked clinical recovery. In long-term transplant recipients with suspected rejection and negative biopsy findings, an integrated multimodal diagnostic strategy may support timely clinical decision-making, with CMR serving as an adjunct rather than a replacement for EMB.
Source: BMC Cardiovascular Disorders
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $3,090
OpenAlex ID: W7221759596
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