title: Usefulness of Two-Dimensional Strain Parameters to Diagnose Acute Rejection after Heart Transplantation.
abstract: BACKGROUND
  Acute cellular rejection (ACR) is still a relevant complication after orthotopic heart transplantation. The diagnosis of ACR is based on endomyocardial biopsy (EMB). Recent advances in two-dimensional strain imaging may allow early noninvasive detection of ACR. The objective of this study was to analyze the usefulness of conventional and new echocardiographic parameters to exclude ACR after orthotopic heart transplantation.
  
  
  METHODS
  Thirty-four consecutive adult heart transplant recipients admitted to a single center between January 2010 and December 2012 for orthotopic heart transplantation were prospectively included. A total of 235 pairs of EMB and echocardiographic examination were performed. A median of seven studies per patient (interquartile range, six to eight studies per patient) were performed during the first year of follow-up. Classic echocardiographic parameters; speckle-tracking-derived left ventricular (LV) longitudinal, radial, and circumferential strain; and global and free wall right ventricular (RV) longitudinal strain were analyzed.
  
  
  RESULTS
  ACR was detected in 26.4% of EMB samples (n = 62); 5.1% (n = 12) required specific treatment (ACR degree ≥ 2R). Lower absolute values of global LV longitudinal strain and free wall RV longitudinal strain were present in patients with ACR degree ≥ 2R compared with those without ACR (13.7 ± 2.7% vs 17.8 ± 3.4% and 16.6 ± 3.6% vs 23.3 ± 5.2%, respectively). An average LV longitudinal strain < 15.5% had 85.7% sensitivity, 81.4% specificity, 98.8% negative predictive value, 25.0% positive predictive value, and 81.7% accuracy for the presence of ACR degree ≥ 2R. Free wall RV longitudinal strain < 17% had 85.7% sensitivity, 91.1% specificity, 98.8% negative predictive value, 42.9% positive predictive value, and 90.7% accuracy for ACR degree ≥ 2R. Both variables were normal in 106 echocardiograms (57.6%); none of these patients presented with ACR degree ≥ 2R.
  
  
  CONCLUSIONS
  The combination of two new echocardiographic measures, global LV and RV free wall longitudinal strain, may be able to identify a group of heart transplant patients who are unlikely to have ACR. If these findings are confirmed independently, it may be possible to use LV and RV strain measures as reliable tools to exclude ACR and to reduce the burden of repeated EMB.
authors.affiliation: Department of Cardiac Imaging, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Spain. Electronic address: susana.mingo.sm@gmail.com.
authors.forename: Susana
authors.initials: S
authors.lastname: Mingo-Santos
authors.affiliation: Department of Cardiac Imaging, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Spain.
authors.forename: Vanessa
authors.initials: V
authors.lastname: Moñivas-Palomero
authors.affiliation: Department of Cardiac Imaging, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Spain; University Hospital Quirón Madrid, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain.
authors.forename: Inés
authors.initials: I
authors.lastname: Garcia-Lunar
authors.affiliation: Department of Cardiac Imaging, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Spain.
authors.forename: Cristina D
authors.initials: CD
authors.lastname: Mitroi
authors.affiliation: Department of Cardiac Imaging, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Spain.
authors.forename: Josebe
authors.initials: J
authors.lastname: Goirigolzarri-Artaza
authors.affiliation: Department of Cardiac Imaging, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Spain.
authors.forename: Betsaida
authors.initials: B
authors.lastname: Rivero
authors.affiliation: Department of Interventional Cardiology, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Spain.
authors.forename: Juan F
authors.initials: JF
authors.lastname: Oteo
authors.affiliation: Department of Cardiac Surgery, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Spain.
authors.forename: Evaristo
authors.initials: E
authors.lastname: Castedo
authors.affiliation: Department of Cardiac Imaging, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Spain.
authors.forename: Jesús
authors.initials: J
authors.lastname: González-Mirelis
authors.affiliation: Department of Cardiac Imaging, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Spain.
authors.forename: Miguel A
authors.initials: MA
authors.lastname: Cavero
authors.affiliation: Department of Heart Failure, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Spain.
authors.forename: Manuel
authors.initials: M
authors.lastname: Gómez-Bueno
authors.affiliation: Department of Heart Failure, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Spain.
authors.forename: Javier
authors.initials: J
authors.lastname: Segovia
authors.affiliation: Department of Heart Failure, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Spain.
authors.forename: Luis
authors.initials: L
authors.lastname: Alonso-Pulpón
mesh_terms: D000208:Acute Disease; D000328:Adult; D000367:Age Factors; D019540:Area Under Curve; D015331:Cohort Studies; D004452:Echocardiography / Q000379:methods*; D005260:Female; D006084:Graft Rejection / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000276:immunology / Q000473:pathology*; D016027:Heart Transplantation / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D007091:Image Processing, Computer-Assisted; D007111:Immunity, Cellular; D015994:Incidence; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D012372:ROC Curve; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D012737:Sex Factors; D013030:Spain; D014181:Transplantation Immunology / Q000502:physiology; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging
keywords: Acute rejection; Heart transplantation; Speckle-tracking; Strain