title: Improved Detection of Cardiac Allograft Vasculopathy: A Multi-Institutional Analysis of Functional Parameters in Pediatric Heart Transplant Recipients.
abstract: BACKGROUND
  Recent guidelines recommend assessment of systolic function and filling pressures to augment angiographic grading of cardiac allograft vasculopathy (CAV); however, no data exist on the utility of these guidelines.
  
  
  OBJECTIVE
  The aims of this study were to evaluate whether the assessment of systolic and diastolic graft function, in addition to angiography, improves recognition of patients at high risk of graft loss and to assess the ability of adult filling-pressure thresholds to discriminate graft dysfunction in pediatric patients.
  
  
  METHODS
  This study reviewed Pediatric Heart Transplant Study data from 1993 to 2009. Graft dysfunction was defined as significant systolic dysfunction (ejection fraction [EF] <45%) or the presence of restrictive hemodynamic features. Additional pediatric hemodynamic cutpoints of right atrial pressure (RAP) >12 mm Hg or pulmonary capillary wedge pressure (PCWP) >15 mm Hg were analyzed.
  
  
  RESULTS
  In the study, 8,122 angiograms were performed in 3,120 patients, and 70% of patients had at least 1 angiogram. Angiographic incidence of CAV was 5%, 15%, and 28% at 2, 5, and 10 years, respectively, and most disease was mild. The presence of graft dysfunction identified patients at greater risk for graft loss even in children with mild angiographic vasculopathy (p < 0.0001). An RAP >12 mm Hg or a PCWP >15 mm Hg was sufficient to detect patients at high risk of graft loss even with mild angiographic disease.
  
  
  CONCLUSIONS
  Patients with only mild angiographic CAV have significantly better outcomes than do patients with moderate or severe disease. The presence of an EF <45%, an RAP >12 mm Hg, or a PCWP >15 mm Hg identifies children at increased risk of graft loss even in the presence of only mild angiographic vasculopathy.
authors.affiliation: Department of Pediatrics, Children's Hospital & Medical Center, University of Nebraska, Omaha, Nebraska. Electronic address: skindel@childrensomaha.org.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Kindel
authors.affiliation: Department of Pediatrics, Children's Hospital & Regional Medical Center, University of Washington, Seattle, Washington.
authors.forename: Yuk M
authors.initials: YM
authors.lastname: Law
authors.affiliation: Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital & Medical Center, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Clifford
authors.initials: C
authors.lastname: Chin
authors.affiliation: Department of Pediatrics, Great Ormond Street Hospital, London, United Kingdom.
authors.forename: Michael
authors.initials: M
authors.lastname: Burch
authors.affiliation: Department of Surgery, University of Alabama Birmingham, Birmingham, Alabama.
authors.forename: James K
authors.initials: JK
authors.lastname: Kirklin
authors.affiliation: Department of Surgery, University of Alabama Birmingham, Birmingham, Alabama.
authors.forename: David C
authors.initials: DC
authors.lastname: Naftel
authors.affiliation: Department of Surgery, University of Alabama Birmingham, Birmingham, Alabama.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Pruitt
authors.affiliation: Department of Pediatrics, Duke Children's Hospital, Durham, North Carolina.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Carboni
authors.affiliation: Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois.
authors.forename: Anna
authors.initials: A
authors.lastname: Arens
authors.affiliation: Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina.
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Atz
authors.affiliation: Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
authors.forename: William J
authors.initials: WJ
authors.lastname: Dreyer
authors.affiliation: Department of Pediatrics, Sibley Heart Center, Children's Health Care of Atlanta, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: William T
authors.initials: WT
authors.lastname: Mahle
authors.affiliation: Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois.
authors.forename: Elfriede
authors.initials: E
authors.lastname: Pahl
mesh_terms: D000293:Adolescent; D064591:Allografts / Q000098:blood supply / Q000503:physiopathology; D016280:Atrial Function, Right; D002648:Child; D002675:Child, Preschool; D017023:Coronary Angiography / Q000379:methods / Q000706:statistics & numerical data; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology; D003331:Coronary Vessels / Q000000981:diagnostic imaging / Q000503:physiopathology; D005260:Female; D006084:Graft Rejection / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control; D016027:Heart Transplantation / Q000009:adverse effects* / Q000379:methods / Q000706:statistics & numerical data; D006439:Hemodynamics; D006801:Humans; D007223:Infant; D053208:Kaplan-Meier Estimate; D008297:Male; D011669:Pulmonary Wedge Pressure; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D006113:United Kingdom; D014481:United States; D014654:Vascular Patency
keywords: chronic rejection; coronary artery; graft loss; heart transplant; hemodynamics; vasculopathy