Prognostic Value of Dobutamine Stress Echocardiography in Heart Transplant Recipients

Abstract

Dobutamine stress echo (DSE) carries a class IIa recommendation for screening of cardiac allograft vasculopathy (CAV). Positive DSEs have a modest ability to predict development of CAV, but normal DSE has a low negative predictive value for CAV. Ability of a positive DSE to predict outcomes is controversial. Outcomes following a normal DSE have not been assessed in large, modern cohorts. We sought to analyze the prognostic value of DSE in heart transplant recipients. All adult heart transplants performed at our institution from 2000 to 2010 were reviewed. Multi organ, recipients who expired within the first year, and those who did not have a DSE were excluded. Patients were grouped according to their DSE result and CAV grade and survival were analyzed. We also analyzed outcomes in patients with a normal DSE and predictors for CAV in this cohort. Unpaired t-test used for analysis. Kaplan-Meier survival curves generated. P value <0.05 considered significant. 179 (mean age 56.6 yrs, 77.6% male) heart transplant recipients were included. 26 (14.5%) patients had a positive DSE. 143 (79.9%) patients subsequently underwent coronary angiography [median duration 9 (1.1 - 17.2) yrs after transplant]. Positive DSE was associated with development of angiographically significant CAV (40% vs 12.2%, P=0.0015) and higher grade CAV (mean grade 1.2±1.2 vs 0.6±0.8, P=0.0077). Those with a positive DSE had a worse 10 yr survival (45.8% vs 68.7%, P=0.0092). Of those with a normal DSE, 15 (12.2%) developed significant CAV. In the normal DSE cohort, there were no differences in demographics, CMV mismatch status, HLA DR mismatch level or donor age between those who developed significant CAV and those who did not. Following a normal DSE, there was no difference in 10 yr survival (80% vs 77.7%, P=0.88) between those who developed and did not develop CAV. Positive DSE is associated with development of significant CAV and worse survival. Normal DSE is associated with better survival, regardless of development of CAV.