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Discrepancy between pre- and post-transplant diagnosis of end-stage dilated cardiomyopathy
G Bortman1, M Sellanes, D S Odell
1Department of Internal Medicine, University of Nebraska Medical Center, Omaha 68198-2265.
Insights
Accurate pretransplant heart failure diagnosis is crucial for patient management and prognosis. Current diagnostic methods like echocardiography and coronary angiography have limitations, especially for idiopathic dilated cardiomyopathy (IDC).
Area of Science:
- Cardiology
- Transplant Surgery
- Pathology
Background:
- Accurate pretransplant diagnosis of heart failure is essential for appropriate management and predicting patient outcomes.
- Idiopathic dilated cardiomyopathy (IDC) and ischemic cardiomyopathy are common pretransplant diagnoses, but differentiating them can be challenging.
- Limitations exist in current diagnostic tools such as echocardiography and coronary angiography for precise etiological determination.
Purpose of the Study:
- To compare pretransplant diagnoses with explanted heart findings in cardiac transplant recipients.
- To evaluate the diagnostic accuracy of coronary angiography and echocardiography in identifying the cause of heart failure, particularly IDC.
- To highlight the impact of accurate diagnosis on treatment strategies and patient prognosis.
Main Methods:
- Retrospective analysis of 112 cardiac transplant recipients.
- Comparison of pretransplant clinical diagnosis with macroscopic and microscopic examination of explanted hearts.
- Review of diagnostic procedures including coronary angiography, endomyocardial biopsy, and echocardiography.
Main Results:
- Severe coronary artery disease was confirmed in all patients initially diagnosed with ischemic cardiomyopathy.
- Significant discrepancies were found in patients diagnosed with IDC, including undiagnosed left ventricular hypertrophy and acute myocarditis.
- Coronary angiography revealed "normal" findings in some patients later found to have severe coronary artery disease.
- Echocardiography failed to detect left ventricular hypertrophy in 11 patients with presumed IDC.
Conclusions:
- An in-depth etiological investigation is recommended for all heart failure patients, irrespective of clinical presentation.
- Current diagnostic modalities have limitations in accurately diagnosing IDC and identifying underlying causes.
- Improving diagnostic techniques is necessary for better patient management and prognostication in heart failure.
Abstract:
A pretransplant diagnosis was compared with the diagnosis made after macroscopic and microscopic examination of the explanted hearts in 112 cardiac transplant recipients. A coronary angiogram was recorded in 87.5% and endomyocardial biopsy was performed in 12.5% of patients within 1 year of the transplant. Echocardiograms were obtained in all patients. Before transplantation, 57.1% of patients were classified as having ischemic cardiomyopathy and 33.9% were classified as having idiopathic dilated cardiomyopathy (IDC). At explantation, severe coronary artery disease was found in all patients with a pretransplant diagnosis of ischemic cardiomyopathy, in 9 patients with a pretransplant diagnosis of IDC (6 of them had a "normal" pretransplant angiograms), and in 3 of the 4 patients with presumptive alcoholic cardiomyopathy. Left ventricular hypertrophy, undetected on echocardiography, was found at autopsy in 11 patients with presumed IDC, and acute myocarditis was found in 3 patients with a pretransplant diagnosis of IDC. A correct pretransplant diagnosis can lead to different management (e.g., bypass surgery rather than transplant), and may also portend different pre- and post-transplant prognoses. The results of this study suggest that an "in-depth" search for a cause should be conducted in all patients with heart failure, regardless of their clinical presentation. Our study also emphasizes the limitations of coronary angiography and echocardiography in patients with IDC and the need for improving current diagnostic techniques in these patients.