Echocardiography Surveillance of Rejection after Heart Transplant without Endomyocardial Biopsy

Abstract

Purpose Surveillance for acute rejection (AR) and cardiac allograft vasculopathy ( CAV) is essential for graft and patient survival. CAV can arise and progress without symptoms and subclinical AR can facilitate CAV .Standard surveillance of AR and CAV is based on routine endomyocardial biopsies (EMBs) and coronary angiographies (CA) at predefined intervals , 9 to 13 times during first post transplant year , there after 3-4 biopsy annually . These invasive screening tests are distressing ,costly and not without complications , yet they cannot identify all sub-clinical ARs . We adopted Biospy free Echocardiography surveillance for detection and treatment of Rejection . Methods From June 2016 till August 2020 , 12 heart transplant recipients,7 male and 5 female , were followed by Echocardiography with Doppler Tissue / strain imaging every 3 months or earlier if indicated. Routine Complete Blood Count , Renal &Liver Function test, Cyclosporine or Tacrolimus level also done .Eleven recipients are free of any rejection.Total Echo-surveillance follow up in study is > 510 months. Results Doppler tissue-imaging (DTI) and strain-imaging for myocardial wall motion and deformation analysis, allowed quantification of minor myocardial dysfunction for early detection of subclinical AR and CAV. Two patients had mild rejection Grade IIB were treated by increasing dose of steroid and raising level of Calcineurine inhibitor. One recipient found to have acute rejection on Echocardiography ,EMB, proved grade III rejection ,treated with Methyl prednisolone, Anti-thymic antibody Conclusion DTI and strain-imaging is an important tool enabling more efficient AR monitoring with fewer EMBs instead of routine EMB-screenings. Myocardial velocity and deformation imaging is also allows early detection of myocardial dysfunction induced by CAV, prognostic evaluation of CAV and timing of CAs aimed to reduce the number of routine CA-screenings. Donor specific antibody with protocol Echocardiography or same in symptomatic patients can yield good surveillance without endomyocardial biopsy.