title: Increased myocardial performance index correlates with biopsy-proven rejection in pediatric heart transplant recipients.
abstract: BACKGROUND
  To date, cardiac catheterization and endomyocardial biopsy have been considered the "gold standard" for rejection surveillance after heart transplantation. Factors such as patient size (i.e., infant transplantation), loss of vascular access after repeated catheterizations, and anesthesia requirements all present unique problems and risks related to pediatric rejection surveillance. Therefore, additional methods to monitor for rejection in a non-invasive, reliable and frequent manner have been sought. We studied the utility of echocardiographic measurement of the left ventricular myocardial performance index (LVMPI), a reproducible measure of combined systolic and diastolic performance, in pediatric heart transplant recipients as a method of identifying acute rejection.
  
  
  METHODS
  Two-dimensional/Doppler echocardiographic studies (n = 36) were performed on 21 cardiac transplant patients (ages 6.2 to 21.9 years) at the time of endomyocardial biopsy. The LVMPI, the sum of the isovolumic contraction time and isovolumic relaxation time divided by aortic ejection time, was determined at each study, as well as other echocardiographic measures of systolic and diastolic function. Patients were grouped by concurrent histologic rejection grade and the results compared between groups.
  
  
  RESULTS
  Significant differences in LVMPI (p < 0.001) were noted between patients with no rejection (Grade 0; n = 23) and those with moderate to severe rejection (Grade 3; n = 5), as well as between those with no rejection and those with focal moderate (Grade 2; n = 8) rejection (p < 0.05). The LVMPI was 0.42 +/- 0.03 (mean +/- SEM) for the group without rejection, 0.57 +/- 0.06 for those with Grade 2 rejection and 0.73 +/- 0.05 for those with Grade 3 rejection. Although 9 of the 23 studies in the non-rejection group had LVMPI values exceeding 0.44 (upper threshold value), 12 of 13 patients in the rejection groups exceeded this threshold. LVMPI >or= 0.64 was associated with significant rejection in all cases in this study (n = 7). No significant differences were noted between groups for left ventricular ejection fraction or shortening fraction, percent septal or posterior wall thickening, left ventricular mass index or mitral valve deceleration time. In addition, for those individual patients with multiple studies, the LVMPI consistently increased with higher rejection grades and decreased after therapy.
  
  
  CONCLUSIONS
  In this series, increased LVMPI correlated with biopsy-proven rejection, and frequent serial assessments using this technique may provide a relatively sensitive non-invasive means of rejection surveillance after pediatric cardiac transplantation. False positive results may be encountered, likely due to alterations in diastolic function that have been previously observed in transplant recipients.
authors.affiliation: Department of Pediatrics (Cardiology), University of Florida College of Medicine, Gainesville, Florida 32610, USA.
authors.forename: Glenn T
authors.initials: GT
authors.lastname: Leonard
authors.forename: F Jay
authors.initials: FJ
authors.lastname: Fricker
authors.forename: Debra
authors.initials: D
authors.lastname: Pruett
authors.forename: Kelli
authors.initials: K
authors.lastname: Harker
authors.forename: Barbara
authors.initials: B
authors.lastname: Williams
authors.forename: Kenneth O
authors.initials: KO
authors.lastname: Schowengerdt
mesh_terms: D000293:Adolescent; D000328:Adult; D001706:Biopsy; D002648:Child; D003971:Diastole; D015150:Echocardiography, Doppler; D005189:False Positive Reactions; D005260:Female; D006084:Graft Rejection; D016027:Heart Transplantation; D006801:Humans; D008297:Male; D009206:Myocardium / Q000473:pathology; D011237:Predictive Value of Tests; D011379:Prognosis; D012016:Reference Values; D013599:Systole; D016277:Ventricular Function, Left