Abstract Background Endomyocardial biopsy (EBM) and invasive angiography (ICA) are the gold standard for the detection of graft rejection (GR) and coronary allograft vasculopathy (CAV). Non-invasive imaging strategies are used to detect such complications in heart transplant (HT) recipients. Methods We performed a prespecified systematic review and meta-analysis of studies reporting on the diagnostic accuracy of echocardiography, cardiac magnetic resonance (CMR), single photon emission computed tomography (SPECT), and positron emission tomography (PET) to diagnose CAV and ACR. Clinical utility was represented with decision curves. Results We identified 80 studies pooling 10,416 HT recipients (mean age years, 54% males). The median prevalence was 20% for CAV and 25% for GR. For detecting CAV, stress CMR yielded the highest accuracy compared to stress echocardiography and SPECT, with areas under the curve (AUC) of 0.811(95%CI0.49–0.95), 0.752(0.61–0.85), and 0.752(0.68–0.81). For GR, parametric CMR demonstrated the higher diagnostic performance (AUC 0.85495%CI0.76–0.91 for T1 and of 0.84595%CI0.75–0.91 for T2 mapping, respectively). Conclusion CMR shows high performance for detecting CAV and GR. Parametric CMR is likely the most accurate method for GR surveillance. Data is limited on quantitative stress perfusion; direct comparisons between quantitative stress CMR and PET are lacking for CAV detection.Decision curves for CAV and GR Included studies
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