Reliability of tissue Doppler wall motion monitoring after heart transplantation for replacement of invasive routine screenings by optimally timed cardiac biopsies and catheterizations.
BACKGROUND
Invasive screenings at predefined time intervals for acute rejection and transplant coronary artery disease (TxCAD) are standard procedures. However, cardiac biopsies and catheterizations are distressing and risky for the patients and are also costly. We assessed the reliability of pulsed-wave tissue Doppler imaging (PW-TDI) for the timing of invasive examinations in heart recipients in an attempt to avoid unnecessary endomyocardial biopsies (EMBs) and catheterizations.


RESULTS
PW-TDI obtained at the basal left ventricular posterior wall before 408 EMBs and 293 catheterizations was tested for its diagnostic value regarding rejection and TxCAD with the use of International Society of Heart and Lung Transplantation biopsy grading, coronary angiography, and intravascular ultrasound as standards. Early diastolic peak wall motion velocity and relaxation time showed high sensitivities for clinically relevant rejection diagnosis (90.0% and 93.3%, respectively). The negative and positive predictive values for rejection of diastolic parameter changes appeared high enough (up to 96% and 92%, respectively) to allow a reliable noninvasive PW-TDI monitoring with efficiently timed, instead of routinely scheduled, EMBs. At definite cutoff values for systolic parameters, the probability for TxCAD reached 92% to 97%. The Fisher classification functions allowed TxCAD exclusion with 80% probability.


CONCLUSIONS
Without diastolic parameter changes, acute rejection can be practically excluded, and serial PW-TDI can save patients from routine EMBs. The high specificity and negative predictive value for TxCAD of reduced systolic peak velocities and extended systolic time allow optimized timed catheterizations. Peak systolic velocity and systolic time allow diagnostic classifications that enable patients without known TxCAD but with high risk for catheterization to be spared routine angiographies.
Dandel
M
M
Deutsches Herzzentrum Berlin, the Department of Cardiothoracic and Vascular Surgery, Berlin, Germany. dandel@dhzb.de
Hummel
M
M
Müller
J
J
Wellnhofer
E
E
Meyer
R
R
Solowjowa
N
N
Ewert
R
R
Hetzer
R
R
D000328:Adult; D001706:Biopsy; D006328:Cardiac Catheterization; D003327:Coronary Disease / Q000175:diagnosis / Q000209:etiology; D015716:Electrocardiography, Ambulatory; D006084:Graft Rejection / Q000175:diagnosis* / Q000209:etiology; D016027:Heart Transplantation / Q000009:adverse effects / Q000276:immunology; D006801:Humans; D009206:Myocardium / Q000473:pathology; D011237:Predictive Value of Tests; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D013997:Time Factors; D018617:Ultrasonography, Doppler, Pulsed