Pediatric transplantation
Identifying cardiac transplant rejection in children: diagnostic utility of echocardiography, right heart catheterization and endomyocardial biopsy data

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Abstract

Background

There has been a continued search for alternative diagnostic techniques that do not necessitate endomyocardial biopsy for diagnosing rejection in cardiac transplant recipients. The purpose of this study is to evaluate the role of echocardiography and hemodynamic catheterization data compared with endomyocardial biopsy results, in rejection surveillance for the pediatric heart transplant recipient.

Methods

A prospective, blinded evaluation was performed utilizing echocardiographic and standard right heart catheterization parameters to predict acute rejection episodes.

Results

Forty-nine patients underwent 281 biopsies. Two groups were defined: those with Grade <2 rejection and those with grade ≥2 rejection. None of the echocardiographic variables showed significant differences between the study groups and all group data were within normal limits. Mixed venous saturation, mean right atrial pressure, right ventricular end-diastolic pressure and mean pulmonary artery pressure were found to be statistically significant between groups. Receiver-operator characteristic (ROC) curves were constructed to determine the extent to which the various parameters were clinically useful. The ROC found little clinical usefulness for all variables, including those found to be statistically significant.

Conclusions

Differences in both echocardiographic and hemodynamic data were not clinically significant between the 2 groups of patients. Although many of the catheterization-derived parameters were statistically significant, they did not permit effective discrimination between groups. This is the only clinically relevant application of such data and may explain the conflicting previous reports. It is only through analyses such as ROC that the clinical application (or lack thereof) can be appreciated in this population.

Section snippets

Patients

A prospective, blinded evaluation was performed at Stanford University, with data collection from January 1, 1999 to June 30, 2000. During this time period, data were collected on all pediatric patients (≤18 years of age) undergoing endomyocardial biopsy after cardiac transplantation. The routine biopsy schedule for noninfant patients was: weekly for 4 weeks; bi-weekly for 4 weeks; monthly for months 3 to 6; and every third month thereafter, until 3 years post-transplant. After the third year,

Results

A total of 49 patients underwent a total of 281 biopsies, all of which were included in the study. Patient characteristics are summarized in Table I. There were 177 biopsies (63%) in patients taking cyclosporine, 105 biopsies (37%) in patients taking tacrolimus, and 196 biopsies (70%) in patients taking prednisone.

Discussion

Surveillance for pediatric patients who have undergone cardiac transplantation includes echocardiography and endomyocardial biopsy at routine intervals, with marked interinstitutional variability in specific protocol and practice. Multiple studies have examined the sensitivity and specificity of various echocardiographic measurements with inconsistent results.2, 3, 7 These studies have demonstrated for the most part that echocardiography does not have sufficient predictive value to completely

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    2017, Journal of Heart and Lung Transplantation
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    Previous studies have reported a high prevalence of cardiac dysfunction in adults with heart transplant of both the right ventricle and the left ventricle,32–34 although more recent studies have also described normal cardiac mechanics in this population,35 suggesting that sub-clinical cardiac mechanical dysfunction might not represent a part of the physiologic adaptation of the transplanted heart, but rather may be an early marker of cardiac impairment. In younger populations with heart transplants, some studies have focused on the analysis of cardiac function to identify early markers of acute rejection.36–39 It has been shown that abnormalities in RV function as well as changes in tissue Doppler indices are able to identify patients at risk of developing acute rejection.

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