Clinical heart transplantation
Dobutamine stress echocardiography predicts cardiac events or death in asymptomatic patients long-term after heart transplantation: 4-Year prospective evaluation

https://doi.org/10.1016/j.healun.2003.09.007Get rights and content

Abstract

Background

Cardiac allograft vasculopathy (CAV) remains the major cause of death after cardiac transplantation during long-term follow-up. Nevertheless, annual angiographic evaluation is difficult to perform routinely. We evaluated the value of clinical risk factors and non-invasive testing for cardiac allograft vasculopathy in predicting cardiac events or death in asymptomatic patients with normal ventricular function during long-term follow-up after heart transplantation.

Methods

We studied 39 patients, mean aged 48 ± 13 years, at 86 ± 31 months after heart transplantation. Patients underwent thallium scintigraphy, treadmill stress testing, dobutamine stress echocardiography, and angiography to detect CAV. We prospectively observed all patients an additional 4 years for acute myocardial infarction, congestive heart failure, or death.

Results

Angiography detected CAV in 15 patients (38%). Three patients had acute myocardial infarction and another 7 had congestive heart failure, representing 25% of cardiac events during the study period. Nine deaths (23%) occurred during the same observation time. Univariate analysis showed that increased body mass index, positive dobutamine stress echocardiography results, and positive angiography results were associated significantly with cardiac events or death during follow-up. In the absence of coronary angiography, stepwise logistic regression identified positive dobutamine echocardiography results as the unique independent predictor of cardiac events (p = 0.001) or death (p = 0.002).

Conclusion

Cardiac events and death after heart transplantation increased during long-term follow-up of this population. However, dobutamine stress echocardiography is well tolerated and, in the absence of routine angiographic evaluation, may be a strong predictor of these events.

Section snippets

Study population

We studied 39 of 58 patients who had survived >4 years after orthotopic heart transplantation at the time of initial enrollment. Average age was 48 ± 13 years, and mean follow-up after heart transplantation was 86 ± 31 months. We enrolled patients with normal ventricular systolic function as shown with resting echocardiography, with no symptoms of angina or heart failure, with no episodes of acute rejection, and who adhered to the study protocol. Patients signed a special informed consent in

Results

Of the 39 patients studied, 15 (38.4%) had allograft vasculopathy shown by coronary angiography and characterized by an obstructive coronary lesion of ≥50% in at least 1 vessel at the initial evaluation.

Table 1 shows the association between clinical and laboratory data, and the presence of CAV. The group with CAV had a tendency toward greater weight but with no statistical significance (68.8 ± 13.5 kg vs 78.5 ± 19.1 kg; p = 0.072). Patients with coronary vasculopathy showed greater BMI than

Discussion

Difficulty in detecting and treating CAV remains the major limiting factor for survival after heart transplantation, especially after the 1st year of clinical follow-up. Clinically, the disease is silent because of cardiac denervation, and when symptoms develop, we observe manifestations of advanced disease, such as heart failure, myocardial infarction, and sudden death. Some immune and non-immune risk factors seem to contribute to the development of the disease, but the results in many series

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      Based on that rationale, non-invasive testing to detect CAV has become an attractive option in transplant recipients, and multiple imaging modalities have been investigated as alternative screening tests to extend the interval between ICAs performed after OHT. Multiple studies have evaluated the ability of DSE compared with ICA and showed sensitivity, specificity, PPV and NPV for the diagnosis of CAV to range from 63% to 95%, 55% to 95%, 40% to 92% and 62% to 92%, respectively, depending on the angiographic definitions of CAV used (varying from any angiographic abnormalities to stenosis of ≥50%).9,11–13,20,23,24 The sensitivity and NPV of DSE to detect any stage of CAV found in our study were very low (7% and 41%, respectively).

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