Graft arteriosclerosis-induced myocardial pathology in heart transplant recipients: predictive value of endomyocardial biopsy.
BACKGROUND
Ischemic myocardial pathology resulting from graft arteriosclerosis (GA) includes subendocardial myocyte vacuolization (SEMV), indicative of sublethal ischemic injury, and coagulative myocyte necrosis, acute and healing (CMN), indicative of infarction.


METHODS
To assess the sensitivity and specificity of myocardial pathology resulting from GA in endomyocardial biopsy specimens, we correlated SEMV and CMN in the final three biopsy specimens (mean interval from last biopsy to death 23 +/- 20 days) with autopsy findings from 30 heart transplant recipients who survived more than 3 months and died of GA (n = 16) or of other causes (n = 14). The two groups were similar in other parameters.


RESULTS
Myocardial ischemic injury was present at autopsy in all 16 patients with GA with the following distribution: SEMV (n = 13) nine right ventricle (RV) and left ventricle (LV), four LV only; focal CMN (n = 8) six RV and LV, two LV only; subendocardial infarct (n = 3) three LV only; and transmural infarct (n = 3) one RV, two LV. Ischemic injury was present in the RV of 11 of 16 patients with GA. Of patients without GA, one had SEMV at autopsy; none had infarcts. Ischemic myocardial pathology was present in 10 of 48 biopsy specimens from patients with GA compared with one of 41 biopsy specimens from patients without GA (p < 0.05). The specificity of SEMV on biopsy was 98%, but sensitivity was only 17%. The positive predictive value for ischemic injury was 92%, and negative predictive value was 51%.


CONCLUSIONS
Myocardial pathology resulting from ischemia was present at autopsy in all patients dying of GA. Although more prevalent in the LV, 69% of patients had ischemic myocardial pathology in the RV, where it may be accessible to biopsy. Ischemic myocardial pathology in biopsy specimens is highly specific but far less sensitive, for diagnosing GA.
Winters
G L
GL
Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Schoen
F J
FJ
D000328:Adult; D001706:Biopsy; D002423:Cause of Death; D003324:Coronary Artery Disease / Q000150:complications*; D004699:Endocardium / Q000473:pathology; D005260:Female; D006097:Granulation Tissue / Q000473:pathology; D016027:Heart Transplantation / Q000473:pathology*; D006352:Heart Ventricles / Q000473:pathology; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology* / Q000473:pathology; D017202:Myocardial Ischemia / Q000209:etiology* / Q000473:pathology; D009206:Myocardium / Q000473:pathology*; D009336:Necrosis; D011237:Predictive Value of Tests; D012680:Sensitivity and Specificity; D014184:Transplantation, Homologous; D014617:Vacuoles / Q000648:ultrastructure; D014945:Wound Healing
D007166:Immunosuppressive Agents