1. Date of download: 6/24/2016 Copyright © The American College of Cardiology. All rights reserved. From: Myocardial Perfusion Reserve and Strain-Encoded CMR for Evaluation of Cardiac Allograft Microvasculopathy J Am Coll Cardiol Img. 2016;9(3):255-266. doi:10.1016/j.jcmg.2015.10.012 Associations Between Cardiac Magnetic Resonance and Histological Findings of Cardiac Allograft Vasculopathy Increasing myocardial perfusion reserve index and diastolic strain rates were observed in patients with increasing microvessel luminal radius to wall thickness ratio and increasing capillary density, after exclusion of patients with more than mild macrovascular cardiac allograft vasculopathy. CI = confidence interval. Figure Legend:

2. Date of download: 6/24/2016 Copyright © The American College of Cardiology. All rights reserved. From: Myocardial Perfusion Reserve and Strain-Encoded CMR for Evaluation of Cardiac Allograft Microvasculopathy J Am Coll Cardiol Img. 2016;9(3):255-266. doi:10.1016/j.jcmg.2015.10.012 Analysis by Patient Groups Eighteen patients (29%) with no or mild CAV by invasive angiography exhibited stenotic microvasculopathy by histological criteria. These patients (Group B) exhibited significantly lower myocardial perfusion reserve index and diastolic strain rate compared with patients with no or mild CAV and without microvasculopathy (Group A; n = 36) and similar values compared with those observed in patients with manifest microvasculopathy and macrovasculopathy (Group C; n = 9). CAV = cardiac allograft vasculopathy; NS = nonsignificant. Figure Legend:

3. Date of download: 6/24/2016 Copyright © The American College of Cardiology. All rights reserved. From: Myocardial Perfusion Reserve and Strain-Encoded CMR for Evaluation of Cardiac Allograft Microvasculopathy J Am Coll Cardiol Img. 2016;9(3):255-266. doi:10.1016/j.jcmg.2015.10.012 Receiver Operating Characteristic Analysis Cutoff values of myocardial perfusion reserve index = 1.75 (A) and early diastolic strain rate = 75/s (B) demonstrated sensitivities of 61%, and specificities of 78% and 86%, respectively, for the prediction of stenotic microvasculopathy by pre-defined histological criteria, after exclusion of patients with stenotic macrovasculopathy. AUC = area under the curve; other abbreviations as in Figure 1. Figure Legend:

4. Date of download: 6/24/2016 Copyright © The American College of Cardiology. All rights reserved. From: Myocardial Perfusion Reserve and Strain-Encoded CMR for Evaluation of Cardiac Allograft Microvasculopathy J Am Coll Cardiol Img. 2016;9(3):255-266. doi:10.1016/j.jcmg.2015.10.012 2 Representative Patient Cases Our first patient (A to H) exhibits normal microvessels (A), high capillary density (B), and only mild cardiac allograft vasculopathy invasive angiography (G and H). Corresponding cardiac magnetic resonance measures demonstrated an MPRI of 2.6 (D to F) and global systolic strain and diastolic strain rate of −21% and 95/s, respectively (C). Another patient showed stenotic microvasculopathy (I) and low capillary density (J) by histology, but only mild cardiac allograft vasculopathy by angiographic criteria (O and P). Corresponding cardiac magnetic resonance measures, however, exhibited markedly reduced MPRI of 1.3 (L to N), preserved systolic strain of −18%, and reduced early diastolic strain rate of 55/s (K), strongly indicative of stenotic microvasculopathy. MPRI = myocardial perfusion reserve index. Figure Legend:

5. Date of download: 6/24/2016 Copyright © The American College of Cardiology. All rights reserved. From: Myocardial Perfusion Reserve and Strain-Encoded CMR for Evaluation of Cardiac Allograft Microvasculopathy J Am Coll Cardiol Img. 2016;9(3):255-266. doi:10.1016/j.jcmg.2015.10.012 Kaplan-Meier Analysis Patients with no or mild CAV but with stenotic microvasculopathy (Group B) and those with manifest CAV by angiography (Group C) both exhibited significantly higher rates of cardiac events, compared with patients with no or mild CAV and without stenotic microvasculopathy (Group A). Abbreviations as in Figure 2. Figure Legend:

6. Date of download: 6/24/2016 Copyright © The American College of Cardiology. All rights reserved. From: Myocardial Perfusion Reserve and Strain-Encoded CMR for Evaluation of Cardiac Allograft Microvasculopathy J Am Coll Cardiol Img. 2016;9(3):255-266. doi:10.1016/j.jcmg.2015.10.012 Diagnostic Algorithm We propose a possible diagnostic algorithm for the risk stratification of heart transplant after CMR using adenosine stress perfusion or SENC. CMR = cardiac magnetic resonance; LGE = late gadolinium enhancement; PCI = percutaneous coronary intervention; SENC = strain-encoded magnetic resonance; other abbreviations as in Figure 4. Figure Legend: