Early diastolic left ventricular function as a marker of acute cardiac rejection: a prospective serial echocardiographic study.
TL;DR: The hypothesis that acute rejection in cardiac transplant recipients is associated with alteration of early diastolic myocardial function, as expressed by the time interval Te, a parameter derived from digitized M-mode echocardiograms, is tested.
About: This article is published in International Journal of Cardiology.The article was published on 1992-12-01. It has received 17 citations till now. The article focuses on the topics: Heart transplantation.
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TL;DR: Gene expression testing can detect absence of moderate/severe rejection, thus avoiding biopsy in certain clinical settings, and the role of molecular testing for clinical event prediction and immunosuppression management is established.
496 citations
TL;DR: Without diastolic parameter changes, acute rejection can be practically excluded, and serial PW-TDI can save patients from routine EMBs.
Abstract: Background Invasive screenings at predefined time intervals for acute rejection and transplant coronary artery disease (TxCAD) are standard procedures. However, cardiac biopsies and catheterizations are distressing and risky for the patients and are also costly. We assessed the reliability of pulsed-wave tissue Doppler imaging (PW-TDI) for the timing of invasive examinations in heart recipients in an attempt to avoid unnecessary endomyocardial biopsies (EMBs) and catheterizations. Methods and results PW-TDI obtained at the basal left ventricular posterior wall before 408 EMBs and 293 catheterizations was tested for its diagnostic value regarding rejection and TxCAD with the use of International Society of Heart and Lung Transplantation biopsy grading, coronary angiography, and intravascular ultrasound as standards. Early diastolic peak wall motion velocity and relaxation time showed high sensitivities for clinically relevant rejection diagnosis (90.0% and 93.3%, respectively). The negative and positive predictive values for rejection of diastolic parameter changes appeared high enough (up to 96% and 92%, respectively) to allow a reliable noninvasive PW-TDI monitoring with efficiently timed, instead of routinely scheduled, EMBs. At definite cutoff values for systolic parameters, the probability for TxCAD reached 92% to 97%. The Fisher classification functions allowed TxCAD exclusion with 80% probability. Conclusions Without diastolic parameter changes, acute rejection can be practically excluded, and serial PW-TDI can save patients from routine EMBs. The high specificity and negative predictive value for TxCAD of reduced systolic peak velocities and extended systolic time allow optimized timed catheterizations. Peak systolic velocity and systolic time allow diagnostic classifications that enable patients without known TxCAD but with high risk for catheterization to be spared routine angiographies.
144 citations
TL;DR: Plasmapheresis seems to improve outcomes in HRHC, however, cyclophosphamide as a maintenance immunosuppressive drug failed to prevent further humoral rejection episodes.
Abstract: Background: Clinical reports on humoral rejection after heart transplantation showed that these episodes were often more severe than those mediated through T lymphocytes and that the patient’s prognosis was significantly worsened. Methods To evaluate the impact of plasmapheresis on the course of humoral rejection with hemodynamic compromise (HRHC) episodes, we retrospectively investigated the records of 1,108 heart transplant patients. All patients received triple-drug immunosuppression (cyclosporine a, azathioprine, prednisone) and cytolytic antibodies for induction. Between April 1986 and December 1990, HRHC episodes were treated with cortisone boli and cytolytic antibodies for at least 3 days (Group A). Between January 1991 and April 1999, HRHC episodes were treated with cortisone boli, cytolytic antibodies, and plasmapheresis for at least 3 days (Group B). All patients who survived their first HRHC episode received cyclophosphamide instead of azathioprine as maintenance immunosuppression. Results Altogether we observed 29 HRHC episodes. In 11 cases, no therapy could be administered or the therapy regimen did not correspond to either Protocol A or B. In the remaining 18 HRHC episodes, 7 episodes in 7 patients were treated without plasmapheresis (Group A), but only 2 patients survived, whereas in 11 HRHC episodes in 6 patients, therapy included plasmapheresis (Group B) and all patients survived ( p = 0.002). Four of 6 patients who received cyclophosphamide after their first HRHC episode experienced at least 1 further HRHC episode. Conclusions Plasmapheresis seems to improve outcomes in HRHC. However, cyclophosphamide as a maintenance immunosuppressive drug failed to prevent further humoral rejection episodes.
73 citations
TL;DR: LV-tor derived from 2D-STE could be of clinical value for non-invasive monitoring of acute rejection in HTx recipients and predicts the change in rejection grade in each patient.
Abstract: Background Reduced left ventricular torsion (LV-tor) has been reported to be associated with acute rejection in heart transplant (HTx) recipients. We investigated the utility of LV-tor analysis derived from 2-dimensional speckle-tracking echocardiography (2D-STE) for detecting allograft rejection. Methods A total of 301 endomyocardial biopsies (EMBs), right heart catheterizations and echocardiograms were performed in 32 HTx recipients. Echocardiography was done within 3 hours from EMB or simultaneously with the procedures. The LV-tor was defined as the difference between apical and basal end-systolic rotations. The LV-tor values with and without cellular rejection were compared. In addition, we investigated whether the change in LV-tor values predicts the change in rejection grade in each patient. The baseline LV-tor value in each patient was defined as a mean value of the first 3 LV-tor measurements obtained when the patient was free from rejection. Results According to the conventional International Society for Heart and Lung Transplantation criteria, 274 biopsies showed a rejection Grade of 0, 1a or 1b (Group AR − ), whereas 27 biopsies were Grade 2 or higher (Group AR + ). LV-tor decreased more in Group AR + than in Group AR − (9.3 ± 0.7 vs 12.2 ± 0.2 degrees, p Conclusion LV-tor derived from 2D-STE could be of clinical value for non-invasive monitoring of acute rejection in HTx recipients.
48 citations
TL;DR: Daily recording of the IMEG can reliably detect early stages of acute rejection episodes, and immediate rejection treatment seems to keep the incidence of TVP low, and it appears better than all the other rejection monitoring protocols currently in use.
43 citations
References
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TL;DR: The survey shows significant interobserver and interlaboratory variation in measurement when examining the same echoes and indicates a need for ongoing education, quality control and standardization of measurement criteria.
Abstract: Four hundred M-mode echocardiographic surveys were distributed to determine interobserver variability in M-mode echocardiographic measurements. This was done with a view toward examining the need and determining the criteria for standardization of measurement. Each survey consisted of five M-mode echocardiograms with a calibration marker, measured by the survey participants anonymously. The echoes were judged of adequate quality for measurement of structures. Seventy-six of the 400 (19%) were returned, allowing comparison of interobserver variability as well as examination of the measurement criteria which were used. Mean measurements and percent uncertainty were derived for each structure for each criterion of measurement. For example, for the aorta, 33% of examiners measured the aorta as an outer/inner or leading edge dimension, and 20% measured it as an outer/outer dimension. The percent uncertainty for the measurement (1.97 SD divided by the mean) showed a mean of 13.8% for the 25 packets of five echoes measured using the former criteria and 24.2% using the latter criteria. For ventricular chamber and cavity measurements, almost one-half of the examiners used the peak of the QRS and one-half of the examiners used the onset of the QRS for determining end-diastole. Estimates of the percent of measurement uncertainty for the septum, posterior wall and left ventricular cavity dimension in this study were 10--25%. They were much higher (40--70%) for the right ventricular cavity and right ventricular anterior wall. The survey shows significant interobserver and interlaboratory variation in measurement when examining the same echoes and indicates a need for ongoing education, quality control and standardization of measurement criteria. Recommendations for new criteria for measurement of M-mode echocardiograms are offered.
7,649 citations
TL;DR: This work has shown that despite the recent progress in understanding of relaxation of the heart, the underlying mechanisms are still not fully understood and these mechanisms can now be discerned.
Abstract: EARLY DETECTION of impaired relaxation has been emphasized recently for the evaluation of global and regional ventricular function in patients with heart disease. Although early relaxation abnormalities have been found in various cardiac diseases, the underlying mechanisms are not as yet fully understood. Given the recent progress in our understanding of relaxation of the heart,' these mechanisms can now be discerned
465 citations
TL;DR: Left ventricular relaxation abnormality seems to be one of the earliest manifestations of mechanical dysfunction of the human left ventricle and a phenomenon of aging.
Abstract: Left ventricular (LV) relaxation was studied in patients with hypertrophic cardiomyopathy (HCM, n =18), congestive cardiomyopathy (CCM, n = 11), hypertensive heart disease (HHD, n = 8), coronary artery disease (CAD) without left ventricular (LV) asynergy (n = 9) and with LV asynergy (n =17), mitral stenosis (MS, n = 16), and mitral regurgitation (MR, n = 8). The time constant T and peak negative dP/dt were used as indexes of LV relaxation, and 18 normal subjects served as controls. The time constant T was higher in elderly patients among normal contros (r = 0.652, p < 0.01), which suggests that prolongation of relaxation is a phenomenon of aging. The normal value of the time constant T was 33 +/- 8 msec (mean +/- SD), and that of peak negative dp/dt was 1864 +/- 390 mm Hg/sec. The time constant T was significantly higher in HCM (64 +/- 20 msec), CCM (56 +/- 14 msec), CAD without asynergy (53 +/- 16 msec), CAD with asynergy (57 +/- 13 msec) and MS (47 +/- 12 msec). Peak negative dP/dt was significantly lower in HCM (998 +/- 303 mm Hg/sec), CCM (1060 +/- 334 mm Hg/sec), CAD with asynergy (1370 +/- 299 mm Hg/sec), MS (1367 +/- 313 mm Hg/sec) and MR (1139 +/- 305 mm Hg/sec). Although the genesis of LV relaxation abnormality is not clear from this investigation, it seems to have multiple causes. Relaxation abnormality seems to be one of the earliest manifestations of mechanical dysfunction of the human left ventricle.
307 citations
TL;DR: In all groups of patients, except those with rheumatic mitral stenosis, the filling pattern appeared to reflect a discontinuity in the factors governing ventricular filling whose cause was not apparent from the present study.
Abstract: measure of left ventricular volume, estimates offilling rates were also made. The characteristics of left ventricular filling were studied in IO normal subjects, and in 5o patients with different types of heart disease. In normal subjects, the peak rate of increase of left ventricular dimension had a mean value of iI cm/sec, corresponding to a filling rate of880 ml/sec. In the presence of mitral regurgitation due to ruptured chordae tendineae, the peak rate of increase of left ventricular dimension and volume was greatly increased to 22 cm/sec and 2400 ml/sec, respectively, while rheumatic mitral stenosis caused a conspicuous reduction in both (mean 6 9 cm/sec and 2I0 ml/sec). Aortic regurgitation was associated with an increased peak left filling rate of I6oo mllsec, though the rate of change of left ventricular dimension was within normal limits, while left ventricular disease did not appear to be associated with any consistent abnormality. In all groups of patients, except those with rheumatic mitral stenosis, the filling pattern consisted of an initial period of accelerating outward wall movement lasting O-i to o0I3 sec, followed by progressive reduction in velocity until the onset of atrial systole. This pattern appeared to reflect a discontinuity in the factors governing ventricular filling whose cause was not apparent from the present study.
284 citations
TL;DR: Left ventricular echograms were analyzed by computer and compared with results in normal subjects to study left ventricular function in idiopathic hypertrophic subaortic stenosis (IHSS), and there was progressive increase in duration of the rapid filling phase.
Abstract: In order to study left ventricular function in idiopathic hypertrophic subaortic stenosis (IHSS), left ventricular echograms were analyzed by computer and compared with results in normal subjects. Systolic function was consistently normal or above normal even in the presence of severe diastolic abnormalities. Wide variation in diastolic function in IHSS allowed separation of patients into three groups on the basis of the left ventricular peak filling rate. Because of the severe septal hypertrophy and hypokinesia, peak left ventricular filling rate is predominantly determined by the rate of free wall thinning. Patients in group 1 had rapid left ventricular filling rates, those in group 2 had normal filling rates, and those in group 3 had slow filling rates. With reduction in left ventricular peak filling rate caused by impaired free wall thinning, there was progressive increase in 1) duration of the rapid filling phase, 2) delay of mitral valve opening, 3) asynchrony between septum and posterior wall, 4) incidence of angina, and 5) incidence of atrial fibrillation.
196 citations