Rejection with hemodynamic compromise: a dismal prognosis

cardiac rejection (AR) beyond the first post-transplant year, but their need for late AR surveillance is controversial. However, late ARs are linked to both graft failure and allograft coronary disease (ACD). To provide appropriate AR surveillance during late post-transplant periods, we assessed the value of tissue Doppler imaging (TDI) screening for both AR diagnosis and effective use of EMBs. Methods: In 130 patients (post-transplant time 2 years) monitored routinely by TDI, we compared the efficacy of routine EMBs (unrelated to TDI results) with that of diagnostic EMBs (timed by TDI). Routine EMBs were performed during annual follow-up catheterizations. Diagnostic EMBs were performed if TDI detected left ventricular wall motion alterations (relaxation time prolongation and/or reduction of systolic and/or diastolic peak velocities). Results: Among the 98 routine EMBs (98 patients), 89.9% were ISHLT grade 0 and TDI showed no changes. Mild ARs (1A and 1B) were shown in 8.1% of routine EMBs. Two routine EMBs obtained from asymptomatic patients with TDI changes showed ARs of grade 3A. Among the 38 diagnostic EMBs performed in 32 patients with TDI alterations, 7 (18.4%) were ISHLT grade 0, but subsequent coronary angiograms showed either new appearance or aggravation of ACD in 5 cases. All the other 31 diagnostic EMBs showed cellular ARs (32.3% grade 1A and 1B, 9.8% grade 2, 57.9% grade 3A and 3B). Vascular reactions were shown in 71.0% of these EMBs. Systolic velocity reductions of 15% were evident in 81.8% of patients with AR and were shown in all those with clinically relevant ARs ( grade 2 plus 1A and 1B with hemodynamic deterioration and/or vascular rejection). Conclusions: Routine annual EMBs detect only a fraction of relevant late ARs. TDI screenings followed by diagnostic EMBs whenever wall motion alterations are detected increase the efficacy of AR diagnosis and provide an efficient strategy for late post-transplant AR surveillance.