Reverse Takatsubo's Pattern in Donor Hearts Not Associated with Left Ventricular Systolic Recovery

Abstract

Background Left ventricular (LV) dysfunction is the most common reason that potential donor hearts are not allocated. However, a significant proportion of brain-dead donors (BDDs) have transient LV dysfunction, and these allocated hearts have equivalent post-transplant outcomes. It is difficult to determine which potential donors with cardiac dysfunction on initial assessment are likely to recover. Stress-induced cardiomyopathy (SIC) patterns, specifically reverse takatsubo's- LV basal hypokinesis with apical hyperkinesis, are often observed in BDDs, however its association with donor LV recovery remains unclear. We retrospectively reviewed echocardiograms from our OPO's recovery center to determine if specific strain patterns predict functional recovery. Methods All BDDs managed at a single OPO recovery center between 1/1/2015-6/1/2018 with reduced initial LV ejection fraction (LVEF) ≤ 40% were included. Initial echocardiograms were adjudicated for image quality, with donors with poor quality or inability to obtain longitudinal strain (LS) excluded. All echocardiograms were interpreted by a single reader, with segmental and global longitudinal strain (SLS and GLS) analysis conducted in apical views. Composite LV apical and basal SLS obtained in each view were used to quantify apical-to-basal strain ratio. LV recovery was defined as an LVEF ≥ 50% on a subsequent echocardiogram during the evaluation process. Results 54 donors were included in this analysis, 29 (54%) had LV recovery and 25 (46%) donors did not have LV recovery. Donors with LV recovery had higher initial LVEF and greater overall LVEF improvement, with greater average overall LV and RV GLS (Table 1). The LV recovery group also had higher average LV apical and basal LS. However, LV, RV, apical, and basal LS were not independently associated with LV recovery when normalized for initial LVEF. Among all donors, the LV apical-to-basal LS ratio was 2.11 ± 1.7. There was no difference in apical-to-basal strain ratio between LV recovery and no recovery groups. Conclusion Reverse takatsubo's-type pattern with elevated apical-to-basal LS ratio was generally observed among all BDDs with LV dysfunction, however this ratio was not associated with LV recovery. Multiple echocardiographic measures were associated with recovery, including initial LVEF, LV GLS and SLS. However, strain does not appear to provide added predictive value for recovery when accounting for initial LVEF. Additional work, combining imaging and clinical data, is needed to better predict donor LV recovery and thus expand the cardiac donor pool.