DOPPLER AND ECHOCARDIOGRAPHIC INDEXES FOR DETECTION OF ACUTE CARDIAC ALLOGRAFT-REJECTION

Due to the invasive nature of myocardial biopsies, a complication rate of up to 2.5 %, and the limitations, e.g., at focal distribution of rejection, there is a continuous need for reliable, non-invasive parameters in recognizing moderate (grade 2) and severe (grade 3) acute cardiac allograft rejections in patients treated with cyclosporine A. 64 biopsies of 20 patients with previous heart transplantations in the past 3 weeks to 36 months (mean 11 months) were compared prospectively to Doppler and echocardiographic results. Parameters of systolic function such as percent fractional shortening (FS) and systolic wall thickness of the posterior wall (SWT) remained without significant changes at grade 2 and grade 3 rejections. The same is valid for relaxation parameters such as maximum velocity of posterior wall reduction (PTR), the time interval of endsystole to maximum velocity of posterior wall reduction (t(ES)-PTR), and the isovolumic relaxation time (IVRT). Left ventricular filling parameters such as maximum early diastolic flow velocity (VE(max)) increased significantly from 73.3 +/- 15.2 cm/s in the rejection-free interval (grade 0) to 103.9 +/- 15.0 cm/s at grade 2 rejection and 1 01.1 +/- 9.2 cm/s at grade 3 rejection (both p < 0.001). A sensitivity of 50 % and a negative predictive value of 77 % are, however, too low to diagnose or exclude a moderate or severe acute rejection in the individual case. The flow velocity integral of the E wave (IE) and the total diastolic flow velocitry integral (IEA) showed significantly higher values at grade 2 rejections (14.9 +/- 2.2 cm and 17.5 +/- 2.7 cm) (p < 0.001) and grade 3 rejections (1 4.0 +/- 1.4 cm and 15.9 +/- 2.8 cm) (p < 0.001 and 0.01) compared to the grade 0 value (9.4 +/- 2.4 cm and 12.4 +/- 2.1 cm, resp.). Here too, sensitivities for IE and IEA of 45 % and 65 respectively, were too low to allow individual decisions. In contrast, there is a significant increase in diastolic left ventricular posterior wall thickness from 10.5 +/- 0.8 mm (grade 0) to 14.4 +/- 0.9 mm (grade 2) and 16.4 +/- 2.2 mm (grade 3) (both p < 0.001). The same is true for systolic left ventricular posterior wall thickness increasing from 20.0 +/- 1.8 to 26.6 +/- 2. 9 at grade 2 rejection, and 29.3 +/- 2.9 mm at grade 3 rejection (both p < 0.001). Both parameters reach a sensitivity of 100 % and a negative predictive value of 100 % as well as a specifity and positive predictive value of 100 % each. With the exception of one patient who received a hypertrophied heart, these parameters proved suitable for the recognition of moderate and severe rejections even under cyclosporine treatment. The visual finding of ''swollen'' and ''soft'' myocardium in the 2D image could not be confirmed on the basis of corrected gray levels.