MRI to Predict Rejection and Failure in Transplant and Cardiomyopathy Patients

Anesthesia and Vascular Access After final review of protocol eligibility and of MRI safety,
vascular access is obtained and sheaths are secured and covered with a sterile drape for
transfer to the MRI. The catheterization is performed with continuous recording of
electrocardiogram signals, transcutaneous hemoglobin ("pulse") oximetry, and under direct
observation of an anesthesia licensed independent provider.

Diagnostic Cardiac MRI Before MRI catheterization begins, a focused cardiac MRI is performed
to understand cardiac function and localize the proposed catheter trajectory from the access
site into the targeted cardiovascular chambers.

MRI-guided catheterization Next during real-time MRI, a passive catheter is advanced from the
access site into the targeted cardiovascular chambers under imaging guidance. Hemodynamic
measurements (using fluid-filled transducers connected to the catheters) and blood hemoglobin
saturation specimens are obtained from targeted cardiovascular chambers. Additional
clinically-indicated and, if time allows, up to 30 minutes of research MRI is then performed
before the subject is returned to the X-ray system.

Research MR Imaging Additional research cardiac MRI imaging to determine T1 and T2 values is
undertaken next, with 6 short axis slices and one long axis slice positions identified for T1
map and T2 map acquisitions. The ICMR laboratory has a robust experience with acquisition of
parametric mapping sequences. T1 and T2 maps will provide a roadmap for the cardiac biopsy
that the patient requires in the xray suite.

Image Fusion to Guide Endomyocardial Biopsy At the conclusion of the MR imaging and MR-guided
right heart catheterization procedure, the subject is returned to the X-ray suite for cardiac
biopsy. Some cardiac biopsies are obtained in the usual fashion, and some biopsy specimens
are obtained using image overlay software to display the regions of abnormal T1 and T2 onto
the fluoroscopy system.

Conclusion of the procedure Following standard of care EMB, standard of care coronary
angiography is obtained when if clinically indicated, all catheters and sheaths are removed
and the subject is observed for complications in the cardiac procedure recovery unit or
intensive care unit for at least 6 hours.

Diagnostic Echocardiogram Standard clinical data with strain analysis will be collected from
the echocardiogram that is performed as a standard of care. Patients undergo a clinically
indicated echocardiogram exam following the catheterization procedure in the Cardiac Post
Recovery Unit (CPRU).

Blood Tests Serum for creatinine blood test will be collected at the time the clinically
indicated IV is placed. Creatinine Is the standard test used at Children's National to assess
kidney function. A total of 1cc of blood will be drawn to complete the test.

For subjects who consent to the optional study, an additional 5cc of blood work will be drawn
at the time that the intravascular catheter is inserted for the clinically indicated cardiac
catheterization procedure. The blood samples will be identified with the study ID number
only, and will be stored in a secure freezer owned and maintained by the department of
cardiology located at the Sheikh Zayed campus. This blood will be used to identify serum
biomarkers, and to validate the potential use for diagnostic purposes.

Follow-up procedures At the conclusion of the procedure, the subject is returned to the X-ray
table and all catheters are removed. The subject is observed for complications in an advanced
nursing recovery unit or intensive care unit for at least 6 hours. The subject will be
assessed for early and late complications at the time of discharge, and again approximately
2-6 weeks ± 7 days post procedure.

MRI Image Analysis In all cardiomyopathy and heart transplant patients, T1 measurements will
be performed using offline analysis software according to our laboratory's measurement SOP
for parametric maps. In heart transplant patients only, T2 measurements will be performed
according to our laboratory's measurement SOP for parametric maps. Following measurements,
images will be created for Image Overlay onto the fluoroscopy for patients undergoing
clinically-indicated cardiac biopsy following the catheterization.

Biopsy Sample Analysis All biopsy samples will be evaluated clinically for evidence of
cellular rejection, and a clinical report will be generated per clinical standard of care. In
addition, each of the samples will undergo a separate staining procedure to identify regions
of fibrosis. Digital images will be taken of the stained samples. Image processing software
will be used to quantify percent fibrosis.

Historical Controls (for radiation exposure comparison, and biopsy yield comparison) Age and
diagnosis-matched historical controls will be identified from the last 10 years at Children's
National as a control population for specific purposes of comparing (1) EMB yield without
image overlay and (2) Radiation exposure during X-ray guided right heart catheterization.
Identical information will be obtained and stored in the same 45CFR compliant database.
Historical controls will be identified from the cardiac catheterization database by searching
for age and diagnosis. A waiver of consent will be applicable here, as it would be
inconvenient, insensitive and not feasible to consent families who have already undergone
treatment.

Subjects will not be provided additional information as a result of this research study.

Data will be reviewed in aggregate generating generalizable knowledge not applicable to an
individual subject

Inclusion Criteria:

- Children and adults of any age with heart transplant, suspected or confirmed
cardiomyopathy

- Undergoing clinically-indicated ("medically necessary") cardiovascular catheterization

Exclusion Criteria:

- Cardiovascular instability including hemodynamic instability (such as requiring
significant vasoactive infusion support) or mechanical hemodynamic support.

- Women who are pregnant

- Women who are nursing and who do not plan to discard breast milk for 24 hours

- Exclusion criteria for MRI

- Central nervous system aneurysm clips

- Implanted neural stimulator

- Implanted cardiac pacemaker or defibrillator which are not MR safe or MR
conditional according to the manufacturer

- Cochlear implant

- Ocular foreign body (e.g. metal shavings)

- Implanted Insulin pump

- Metal shrapnel or bullet.

- Exclusion criteria for Gadolinium

- Renal disease with estimated glomerular filtration rate [eGFR] < 30 ml/min/1.73
m2 body surface area

The eGFR will be used to estimate renal function if reported by the laboratory.

The Schwartz equation 33 for estimation of GFR in children as recommended by the NKDEP is
as follows:

GFR (mL/min/1.73 m2) = (k × height) / serum creatinine concentration

where k = constant defined as follows: k = 0.33 in premature infants k = 0.45 in term
infants to 1 year of age k = 0.55 in children to 13 years of age k = 0.70 in adolescent
males (not females because of the presumed increase in male muscle mass, the constant
remains 0.55 for females) Height in cm Serum creatinine in mg/dL