Echocardiographic Assessment After Heart Transplant

Heart transplantation remains the gold-standard therapy for selected patients with end-stage heart failure, yet acute rejection and cardiac allograft vasculopathy (CAV) continue to limit long-term survival. While endomyocardial biopsy and coronary angiography remain the reference standards for diagnosing rejection and CAV, respectively, echocardiography offers a non-invasive, repeatable tool for the longitudinal surveillance of heart transplant recipients. This review summarizes the expected echocardiographic findings following orthotopic heart transplantation according to surgical technique (biatrial versus bicaval) and describes the echocardiographic features of early graft dysfunction, acute allograft rejection, and late graft failure due to cardiac allograft vasculopathy. We also discuss the incremental value of newer echocardiographic techniques-including speckle-tracking-derived strain, myocardial work, and three-dimensional echocardiography-in detecting subclinical left ventricular and right ventricular dysfunction that may precede changes detectable by conventional parameters. No single echocardiographic parameter reliably diagnoses rejection or vasculopathy in isolation; an integrated, multiparametric approach combined with clinical data is required. Emerging techniques hold promise for reducing reliance on invasive surveillance, although further validation in larger, multicenter cohorts is needed. This review aims to provide echocardiographers and transplant cardiologists with a practical, imaging-based framework for the follow-up of heart transplant recipients across the early postoperative period and long-term surveillance.