Identifying cardiac transplant rejection in children: diagnostic utility of echocardiography, right heart catheterization and endomyocardial biopsy data.
BACKGROUND
There has been a continued search for alternative diagnostic techniques that do not necessitate endomyocardial biopsy for diagnosing rejection in cardiac transplant recipients. The purpose of this study is to evaluate the role of echocardiography and hemodynamic catheterization data compared with endomyocardial biopsy results, in rejection surveillance for the pediatric heart transplant recipient.


METHODS
A prospective, blinded evaluation was performed utilizing echocardiographic and standard right heart catheterization parameters to predict acute rejection episodes.


RESULTS
Forty-nine patients underwent 281 biopsies. Two groups were defined: those with Grade <2 rejection and those with grade > or =2 rejection. None of the echocardiographic variables showed significant differences between the study groups and all group data were within normal limits. Mixed venous saturation, mean right atrial pressure, right ventricular end-diastolic pressure and mean pulmonary artery pressure were found to be statistically significant between groups. Receiver-operator characteristic (ROC) curves were constructed to determine the extent to which the various parameters were clinically useful. The ROC found little clinical usefulness for all variables, including those found to be statistically significant.


CONCLUSIONS
Differences in both echocardiographic and hemodynamic data were not clinically significant between the 2 groups of patients. Although many of the catheterization-derived parameters were statistically significant, they did not permit effective discrimination between groups. This is the only clinically relevant application of such data and may explain the conflicting previous reports. It is only through analyses such as ROC that the clinical application (or lack thereof) can be appreciated in this population.
Rosenthal
David N
DN
Department of Pediatrics, Stanford University, Stanford, California, USA. david.rosenthal@stanford.edu
Chin
Clifford
C
Nishimura
Kyra
K
Perry
Stanton B
SB
Robbins
Robert C
RC
Reitz
Bruce
B
Bernstein
Daniel
D
Feinstein
Jeffrey A
JA
D001706:Biopsy; D006328:Cardiac Catheterization; D002648:Child; D004452:Echocardiography; D004699:Endocardium / Q000473:pathology*; D006084:Graft Rejection / Q000175:diagnosis*; D016027:Heart Transplantation / Q000276:immunology*; D006439:Hemodynamics; D006801:Humans; D009206:Myocardium / Q000473:pathology*; D011446:Prospective Studies; D012372:ROC Curve