Clinical Heart TransplantationsFunctional and morphological findings in heart transplant recipients with a normal coronary angiogram: an analysis by dobutamine stress echocardiography, intracoronary Doppler and intravascular ultrasound
Section snippets
Patient population
From 100 consecutive orthotopic heart transplant recipients undergoing scheduled routine coronary angiography in the chronic postoperative phase (≥10 months after transplantation), 56 patients were selected fulfilling the criteria of A) a normal coronary angiogram by visual analysis and B) an adequate echocardiographic image quality. The mean age was 49 ± 11 years, the postoperative interval was 41 ± 31 (10–144) months. Immunosuppressive therapy consisted of cyclosporine (n = 46), tacrolimus (n
Statistics
Data are given as mean ± standard deviation, unless stated otherwise. Unpaired Student′s t-test, Mann-Whitney U-test, or Fisher′s exact test were used, as appropriate, to assess differences between groups. Differences between stress stages were analyzed with a Wilcoxon rank sum test. A p value of <0.05 was considered significant.
Clinical characteristics
Arterial hypertension requiring medical therapy was present in 51 of 56 patients (91%). The mean systolic / diastolic blood pressure at rest before stress echocardiography was 125 ± 17/76 ± 13 mmHg. There were no differences in blood pressure in subgroups of patients with and without abnormal either echocardiographic or IVUS findings. All patients in this study were non-smokers. Fifteen patients (27%) had diabetes mellitus after transplantation; the prevalence of diabetes was not different in
Discussion
Coronary angiography has remained the most commonly used screening method for CAV.2, 3, 5 Several reports exist, however, on rapid progression from a normal angiogram to severe vasculopathy, that in some cases of sudden death after heart transplantation was diagnosed only at necropsy.4, 20 IVUS has been demonstrated to be the most sensitive invasive tool for diagnosis of CAV in vivo.6, 7, 8, 9, 10 IVUS, however, does not allow to investigate the complete coronary artery system as it is
Conclusion
A normal angiogram alone does not exclude relevant CAV in heart transplant recipients. Despite of a normal coronary angiogram, the majority of patients in this study had functional alterations as regional wall motion abnormalities and impaired systolic wall thickening by dobutamine stress echocardiography and morphologic evidence of CAV in the epicardial arteries by IVUS. Measurement of coronary flow velocity reserve, however, does not seem useful to identify patients with abnormal findings by
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Cited by (42)
Initial Intravascular Ultrasound Without a Routine Early Baseline Study in the Evaluation of Cardiac Transplant Vasculopathy has Prognostic Valve
2019, Cardiovascular Revascularization MedicineCitation Excerpt :Our study among many others highlights the important prognostic value of detecting significant intimal thickening on the IVUS studies. It should however be noted that, although IVUS remains the gold standard because it allows early and reproducible detection of transplant vasculopathy by viewing both the actual lumen diameter and the appearance and thickness of the intima and media, other non-invasive methods are currently available [27–29]. These non-invasive tests include dobutamine stress echocardiogram, multidetector CT, and perfusion cardiac magnetic resonance imaging, which when compared to IVUS as the gold standard; have 83–100% sensitivity respectively [27,29].
Vascular Disease of the Transplanted Heart: Physiopathology and Therapeutic Options
2018, Endothelium and Cardiovascular Diseases: Vascular Biology and Clinical SyndromesQuality control of regional wall motion analysis in stress Echo 2020
2017, International Journal of CardiologyFollow-up of heart transplant recipients with serial echocardiographic coronary flow reserve and dobutamine stress echocardiography to detect cardiac allograft vasculopathy
2014, Journal of the American Society of EchocardiographyDetection and imaging of cardiac allograft vasculopathy
2013, JACC: Cardiovascular ImagingCitation Excerpt :The angiographic diagnosis of CAV has prognostic significance for graft survival, patient survival, and adverse cardiac events. However, concern remains regarding the sensitivity of coronary angiography for CAV when compared with IVUS and histopathologic studies (3,61–64). Coronary angiography also exposes patients to the risks of an invasive procedure and necessitates the use of iodinated contrast, which may pose an increased risk of kidney injury in cardiac transplant recipients, among whom chronic kidney disease is a common comorbidity (65).
Task force 6: Coronary artery disease
2005, Journal of the American College of CardiologyCitation Excerpt :Provocative myocardial perfusion imaging can fail to detect ischemia (25,27) although dobutamine echocardiography has been shown to predict subsequent ischemic cardiac events (26,28–31) after the first three to five years post-transplant. In many cardiac transplant centers, a normal stress echocardiogram justifies postponement of annual coronary angiography (26,28–31). Coronary angiography can also underestimate disease severity because of the diffuse nature of the CAD process; intravascular ultrasound studies increase the sensitivity (26).
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Reprint requests: Christoph H. Spes, MD, Dept. of Cardiology, Medizinische Klinik, Klinikum Innenstadt, University of Munich, Ziemssenstr. 1, D-80336 München, Germany.