Reduction of tricuspid annular doppler tissue velocities in pediatric heart transplant patients

Abstract

Background: Orthotopic heart transplantation is a life-saving therapy for children with end-stage heart disease. However, 50% of these transplanted children die or require re-transplantation 12 years later. Progressive deterioration of cardiac function is a common feature of long-term survivors; however, quantitative evaluation of the state of the right ventricle has been lacking. Tissue Doppler imaging (TDI) has been used to measure alterations in right ventricular (RV) function in other illnesses. The purpose of this study was to quantitate abnormalities in tricuspid annular systolic and diastolic velocities as an indicator of RV dysfunction, and to evaluate if time since transplantation and the presence of tricuspid regurgitation are associated with quantitative changes in tricuspid annular velocities in pediatric heart transplant recipients. Methods: TDI was performed and velocities recorded during systole and early and late diastole at the tricuspid annulus, septum and mitral annulus in transplanted patients and in a control group with normal hearts. Pulsed wave Doppler mitral and tricuspid inflows were also measured and the severity of tricuspid regurgitation was estimated using color flow mapping. Patients with biopsy evidence of active cellular rejection or left ventricular ejection fraction of <60% were excluded from study. Results: Thirty-five patients were divided into a normal heart group ( n = 14) and a transplant group ( n = 21), aged from 1 to 23 years. Systolic and early diastolic velocities at the tricuspid annulus and septum in the transplant group were reduced significantly compared with the normal group ( p < 0.05): tricuspid annular systolic, 5.8 ± 1.4 vs 9.4 ± 1.7 cm/sec; early diastolic, −6.4 ± 2.6 vs −9.7 ± 2.6 cm/sec; septum systolic, 3.9 ± 1.5 vs 5.8 ± 1.4 cm/sec; and early diastolic, −6.3 ± 2.4 vs −9.1 ± 2.5 cm/sec. Patients were divided into early (<5 years) and late (>5 years) term groups since transplantation. Tissue velocities at the tricuspid annulus in the late term group had further reduction in systole, 4.9 ± 1.4 vs 6.4 ± 1.1 cm/sec, and early diastole, −5.3 ± 1.5 vs −7.1 ± 2.9 cm/sec ( p < 0.05). Patients with severe tricuspid regurgitation had systolic and early diastolic velocities at the tricuspid annulus that were further reduced. Left ventricular mitral inflow Doppler early/late diastolic ratios became significantly different from the normal group 5 years after transplantation ( p < 0.05). Conclusions: TDI demonstrated that tricuspid annular systolic and early diastolic velocities were abnormal in children after transplantation and became significantly more abnormal with prolonged time after transplantation. These alterations were not dependent on the presence of severe tricuspid regurgitation but appeared to be exacerbated by its presence. Evidence of diastolic left ventricular dysfunction was not detected before 5 years after transplantation in this unselected group. A prospective study may be required to define the evolution and progression of right and left ventricular dysfunction in children after heart transplantation.