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Updated: Aug 19, 2026
Functional Assessment of the Donor Heart During Ex Situ Perfusion: Insights from Pressure-Volume Loops and Surface Echocardiography
Published on: October 11, 2022
Non-invasive evaluation of orthotopic heart transplant rejection by echocardiography
Jing Ping Sun1, Ibrahim A Abdalla, Craig R Asher
1Cardiovascular Imaging Center and Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
Insights
Echocardiographic factors like pericardial effusion and specific mitral inflow patterns can predict acute cardiac allograft rejection in heart transplant patients. While these predictors show promise, they cannot yet replace routine myocardial biopsies.
Area of Science:
- Cardiology
- Transplant Medicine
- Diagnostic Imaging
Background:
- Heart transplant recipients undergo frequent myocardial biopsies to detect acute rejection.
- Developing non-invasive methods to predict rejection could reduce the need for biopsies.
Purpose of the Study:
- Identify demographic and echocardiographic factors predicting acute cardiac allograft rejection.
- Develop a predictive model to potentially decrease the frequency of endomyocardial biopsies.
Main Methods:
- Analyzed 406 echocardiographic studies from 264 heart transplant patients with same-day biopsies (1998-2001).
- Compared echocardiographic variables (2D, pulsed, tissue Doppler) between patients with and without rejection.
- Utilized univariate and multivariate analyses to assess predictive ability.
Main Results:
- Multivariate analysis identified pericardial effusion, short isovolumic relaxation time (IVRT), high mitral inflow E/A ratio, inferior vena cava diameter, and pulmonary vein atrial reversal duration as independent predictors of rejection.
- A simplified model summing abnormal predictors showed increasing rejection probability with more predictors present (15.9% with 0, up to 71.1% with 3).
Conclusions:
- Recipient age, pericardial effusion, IVRT, and mitral inflow E/A ratio are significant predictors of acute cardiac allograft rejection.
- No single or combined predictor was sufficient to eliminate the need for surveillance endomyocardial biopsies.
Background:
Heart transplant recipients require frequent myocardial biopsies to screen for acute rejection. The purpose of this study was to identify demographic and echocardiographic factors associated with transplant rejection and develop a predictive model, which may reduce the number of cardiac biopsies.
Methods:
From January 1998 to December 2001, we performed 406 echocardiographic studies on 264 heart transplant patients who had biopsies performed on the same day. Two-dimensional, pulsed and tissue Doppler echocardiographic variables were compared between patients with and without rejection, and their predictive ability for detecting rejection was determined by uni- and multivariate analyses.
Results:
In 268 biopsies there was no significant rejection (ISHLT Grade <==II), whereas 138 showed rejection (ISHLT Grade > or =IIIa). By multivariate analysis, pericardial effusion, isovolumic relaxation time (IVRT) <90 milliseconds and mitral inflow E/A ratio >1.7, diameter of inferior vena cava and duration of pulmonary vein atrial reversal were independently associated with rejection. Because the odds ratios were similar for all 5 predictors, a simplified model was developed based on the sum of the number of abnormal predictors present (0 to 5). The probability of rejection increased from 15.9%, in the absence of any predictor, to 39.7%, 52.0% and 71.1%, if 1, 2 or 3 predictors were present, respectively.
Conclusions:
Recipient age, pericardial effusion, IVRT and ratio of pulsed Doppler E/A are significant predictors of acute cardiac allograft rejection. However, no single predictor or combination of predictors were powerful enough to eliminate surveillance endomyocardial biopsies.
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