Abstract
BackgroundAcute cellular rejection (ACR) is a major complication after heart transplantation. Endomyocardial biopsy (EMB) remains the gold standard for its diagnosis, but it has concerning complications. We evaluated the usefulness of speckle tracking echocardiography (STE) and biomarkers for detecting ACR after heart transplantation.MethodsWe prospectively studied 60 transplant patients with normal left and right ventricular systolic function who underwent EMB for surveillance 6 months after transplantation. Sixty age- and sex-matched healthy individuals constituted the control group. Conventional echocardiographic parameters, left ventricular global longitudinal, radial and circumferential strain (LV-GLS, LV-GRS and LV-GCS, respectively), left ventricular systolic twist (LV-twist) and right ventricular free wall longitudinal strain (RV-FWLS) were analyzed just before the procedure. We also measured biomarkers at the same moment.ResultsAmong the 60 studied patients, 17 (28%) had severe ACR (grade ≥ 2R), and 43 (72%) had no significant ACR (grade 0 – 1R). The absolute values of LV-GLS, LV-twist and RV-FWLS were lower in transplant patients with ACR degree ≥ 2 R than in those without ACR (12.5% ± 2.9% vs 14.8% ± 2.3%, p=0.002; 13.9° ± 4.8° vs 17.1° ± 3.2°, p=0.048; 16.6% ± 2.9% vs 21.4%± 3.2%, p < 0.001; respectively), while no differences were observed between the LV-GRS or LV-GCS. All of these parameters were lower in the transplant group without ACR than in the nontransplant control group, except for the LV-twist. Cardiac troponin I levels were significantly higher in patients with significant ACR than in patients without significant ACR [0.19 ng/mL (0.09–1.31) vs 0.05 ng/mL (0.01–0.18), p=0.007]. The combination of troponin with LV-GLS, RV-FWLS and LV-Twist had an area under curve for the detection of ACR of 0.80 (0.68–0.92), 0.89 (0.81–0.93) and 0.79 (0.66–0.92), respectively.ConclusionHeart transplant patients have altered left ventricular dynamics compared with control individuals. The combination of troponin with strain parameters had higher accuracy for the detection of ACR than the isolated variables and this association might select patients with a higher risk for ACR who will benefit from an EMB procedure in the first year after heart transplantation.
Highlights
Heart transplantation is the treatment of choice for selected patients with end-stage heart failure [1, 2]
Heart transplant patients have altered left ventricular dynamics compared with control individuals
In accordance with Bader et al [39], we observed that B-type natriuretic peptide (BNP) levels did not predict rejection after heart transplantation, and we suggest that BNP is not clinically useful for the detection of Acute cellular rejection (ACR)
Summary
Heart transplantation is the treatment of choice for selected patients with end-stage heart failure [1, 2]. Significant advances in immunosuppressive therapy have been beneficial in decreasing cardiac allograft rejection, graft failure remains one of the major associated complication [3, 4]. For this reason, adequate monitoring of heart transplant patients to diagnose and initiate specific therapy for transplant rejection in a timely manner is important, albeit challenging. Endomyocardial biopsy (EMB) is the widely accepted gold standard for the diagnosis of acute cellular rejection (ACR) [5] It is invasive and is associated with complications in 0.2 to 5.5% of cases; these complications include tricuspid regurgitation, cardiac perforation and cardiac tamponade [6,7,8,9]. We evaluated the usefulness of speckle tracking echocardiography (STE) and biomarkers for detecting ACR after heart transplantation
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