Clinical Investigation
Echocardiographic Predictors of Heart Transplant Outcome
Coronary Flow Velocity Reserve and Myocardial Deformation Predict Long-Term Outcomes in Heart Transplant Recipients

https://doi.org/10.1016/j.echo.2021.07.012Get rights and content

Highlights

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    CFVR and strain were reduced in HTx patients with CAV.

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    Both were associated with higher risk for mortality and MACE.

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    Combined CFVR and strain provided incremental prognostic value.

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    High values had a negative predictive value of 94.8% to rule out CAV.

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    Combined CFVR and strain are useful for noninvasive CAV surveillance.

Background

After heart transplantation (HTx), invasive coronary angiography is the gold standard for surveillance of cardiac allograft vasculopathy (CAV). Noninvasive CAV surveillance is desirable. The authors examined left ventricular global longitudinal strain (LVGLS) and noninvasive coronary flow velocity reserve (CFVR) related to CAV and prognosis after HTx.

Methods

Doppler echocardiographic CFVR and LVGLS were evaluated in 98 HTx patients. All-cause mortality and major adverse cardiac events (MACE), including hospitalization for heart failure, cardiovascular death, and significant CAV progression, were recorded.

Results

Median follow-up duration was 3.3 years (range: 1.7–5.4 years). Patients with low CFVR (<2.0; n = 20) showed reduced MACE-free survival (hazard ratio, 4.3; 95% CI, 2.2–8.4; P < .0001) and increased all-cause mortality (hazard ratio: 4.7; 95% CI: 2.0–11.3; P < .0001) compared with patients with high CFVR (≥2.0; n = 78). Worsened LVGLS (≥−15.5%) was also a strong independent predictor of MACE and cardiovascular and all-cause mortality. Combined low CFVR and worsened LVGLS provided incremental prognostic value, even after adjustment for CAV and time since HTx. The prevalence of low CFVR increased significantly with CAV severity, and the prevalence of combined low CFVR and/or worsened LVGLS was high in patients with moderate CAV (86%) and those with severe CAV (83%). The negative predictive value of combined high CFVR and improved LVGLS to rule out significant CAV was 94.5% (95% CI, 86.2%–98.4%), whereas the positive predictive value was 39.0% (95% CI, 25.3%–54.3%). The model had sensitivity of 84.2% (95% CI, 63.6%–95.3%) and specificity of 67.5% (95% CI, 56.6%–77.2%) for one or more abnormal parameters.

Conclusions

In HTx patients with severe CAV, a higher prevalence of low CFVR and worsened LVGLS was observed. Both measurements were strong independent predictors of MACE and all-cause mortality in HTx patients. Combined CFVR and LVGLS provided incremental prognostic value and showed an excellent ability to rule out significant CAV and may be considered as part of routine CAV surveillance of HTx patients.

Section snippets

Study Population

In this single-center cohort study, we included 98 HTx patients during their annual or biannual HTx control visit from September 2013 to June 2018. The patient population comprised two different patient groups previously described,11,12 but follow-up data have not been reported. A total of 108 patients were screened. Twelve patients were excluded, as two patients refused to receive adenosine, and in 10 patients, completion of CFVR was not possible because of occluded or narrowed distal left

Demographic and Clinical Data

Table 1 shows baseline characteristics of 96 HTx patients according to CFVR groups. The median time since HTx was 6.9 years (IQR, 1.1–12.1 years). The low-CFVR group (CFVR < 2) had more prevalent CAV than the high-CFVR group (CFVR ≥ 2; P < .001). As aspirin is initiated at our institution when CAV is diagnosed, the low-CFVR group was more likely to be receiving aspirin therapy (P < .01). Time since HTx differed significantly between groups (P < .01), and thus the low-CFVR group was less likely

Discussion

In this prospective cohort study, we demonstrate a significant prognostic value of CFVR and LVGLS in HTx patients. The novel findings are as follows: (1) low CFVR and worsened LVGLS were both strong independent predictors of MACE and all-cause mortality, (2) combining CFVR and LVGLS provided incremental prognostic value, (3) combined CFVR and LVGLS was a strong model to rule out significant CAV, and (4) the incidence of combined low CFVR and/or worsened LVGLS was high in patients with CAV 2 and

Conclusion

Low CFVR and/or worsened LVGLS values were more prevalent in patients with severe CAV, and both measurements were strong independent predictors of MACE and all-cause mortality in HTx patients. Combined CFVR and LVGLS values provided incremental prognostic value and showed excellent ability to rule out significant CAV. Combined CFVR and LVGLS measurements may be considered as part of routine CAV surveillance of HTx patients.

Acknowledgments

We gratefully thank the invasive cardiologists who performed angiographic examinations and Lene Lindenkrone Konrad for echocardiographic assistance.

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    Dr. Bjerre was supported by a research grant from Aarhus University, Denmark.

    Conflicts of interest: None.

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    2021 by the American Society of Echocardiography.