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 r ejection, there is a continuous need for reliable, non-invasive parame ters in recognizing moderate (grade 2) and severe (grade 3) acute card iac allograft rejections in patients treated with cyclosporine A. 64 b iopsies of 20 patients with previous heart transplantations in the pas t 3 weeks to 36 months (mean 11 months) were compared prospectively to Doppler and echocardiographic results. Parameters of systolic functio n such as percent fractional shortening (FS) and systolic wall thickne ss of the posterior wall (SWT) remained without significant changes at grade 2 and grade 3 rejections. The same is valid for relaxation para meters such as maximum velocity of posterior wall reduction (PTR), the time interval of endsystole to maximum velocity of posterior wall red uction (t(ES)-PTR), and the isovolumic relaxation time (IVRT). Left ve ntricular filling parameters such as maximum early diastolic flow velo city (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 re jection 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, ho wever, too low to diagnose or exclude a moderate or severe acute rejec tion in the individual case. The flow velocity integral of the E wave (IE) and the total diastolic flow velocitry integral (IEA) showed sign ificantly 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 fo r IE and IEA of 45 % and 65 respectively, were too low to allow indivi dual decisions. In contrast, there is a significant increase in diasto lic left ventricular posterior wall thickness from 10.5 +/- 0.8 mm (gr ade 0) to 14.4 +/- 0.9 mm (grade 2) and 16.4 +/- 2.2 mm (grade 3) (bot h 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 predict ive value of 100 % as well as a specifity and positive predictive valu e of 100 % each. With the exception of one patient who received a hype rtrophied heart, these parameters proved suitable for the recognition of moderate and severe rejections even under cyclosporine treatment. T he visual finding of ''swollen'' and ''soft'' myocardium in the 2D ima ge could not be confirmed on the basis of corrected gray levels.