Simmonds M B, Lythall D A, Slorach C, Ilsley C D, Mitchell A G, Yacoub M H
Department of Cardiology, Harefield Hospital, Middlesex, UK.
Circulation. 1992 Nov;86(5 Suppl):II259-66.
Doppler echocardiographic studies have previously documented abnormalities of mitral flow during acute rejection similar to those seen in patients with "restrictive" physiology. As central venous flow is known to be abnormal in such patients, it was proposed that examination of superior vena caval flow with Doppler echocardiography might be useful for the detection of acute cardiac rejection.
Thirty orthotopic cardiac transplant patients, 15 of whom had acute cardiac rejection diagnosed by endomyocardial biopsy, were studied within 36 hours of biopsy. Superior vena caval Doppler flow velocities as well as mitral and tricuspid flow velocities were recorded using a Hewlett-Packard Sonos 500/1000 echocardiograph system. Examinations were performed blinded to the biopsy result. Mitral and tricuspid peak early flow velocities in the nonrejector group were similar to those seen in normal subjects (mitral, 70 +/- 5 cm/sec; tricuspid midexpiratory apnea, 50 +/- 11 cm/sec). Superior vena caval flow was abnormal with 13 of 15 patients demonstrating a biphasic pattern of forward flow with dominant diastolic flow. In the 15 patients with acute cardiac rejection, both mitral and tricuspid flow velocities developed a "restrictive"-type pattern with increased peak early flow velocities (mitral, 89 +/- 24 cm/sec; tricuspid midexpiratory apnea, 63 +/- 19 cm/sec; p < or = 0.05 versus nonrejectors) and decreased mitral early flow-velocity deceleration times (rejectors, 97 +/- 26 msec; nonrejectors, 144 +/- 41 msec; p < or = 0.05). The pattern of superior vena caval flow became markedly abnormal with a virtually complete loss of forward systolic flow (rejectors, 4.4 +/- 6.6 cm/sec; nonrejectors, 26.1 +/- 8.8 cm/sec at midexpiratory apnea; p < or = 0.0001). In 10 of 15 patients, systolic forward flow was absent. If acute rejection was defined as forward systolic flow < or = 17 cm/sec, then sensitivity was 100%, specificity was 80%, and predictive accuracy was 90%.
During acute cardiac rejection, forward systolic superior vena caval flow is markedly diminished compared with nonrejectors. This is accompanied by other Doppler echocardiographic features consistent with the development of "restrictive" physiology. It is postulated that the loss of forward systolic flow in the superior vena cava is due to diminished long-axis shortening of the right ventricle associated with acute cardiac rejection.
既往多普勒超声心动图研究已记录到急性排斥反应期间二尖瓣血流异常，类似于“限制性”生理学患者所见。由于已知此类患者中心静脉血流异常，有人提出用多普勒超声心动图检查上腔静脉血流可能有助于检测急性心脏排斥反应。
对30例原位心脏移植患者进行研究，其中15例经心内膜心肌活检诊断为急性心脏排斥反应，在活检后36小时内进行检查。使用惠普Sonos 500/1000超声心动图系统记录上腔静脉多普勒血流速度以及二尖瓣和三尖瓣血流速度。检查时对活检结果不知情。非排斥组二尖瓣和三尖瓣早期血流峰值速度与正常受试者相似（二尖瓣，70±5cm/秒；三尖瓣呼气中期暂停时，50±11cm/秒）。15例患者中有13例上腔静脉血流异常，表现为舒张期血流占主导的双相正向血流模式。在15例急性心脏排斥反应患者中，二尖瓣和三尖瓣血流速度均呈现“限制性”类型模式，早期血流峰值速度增加（二尖瓣，89±24cm/秒；三尖瓣呼气中期暂停时，63±19cm/秒；与非排斥者相比，p≤0.05），二尖瓣早期血流速度减速时间缩短（排斥者，97±26毫秒；非排斥者，144±41毫秒；p≤0.05）。上腔静脉血流模式变得明显异常，收缩期正向血流几乎完全丧失（排斥者，呼气中期暂停时为4.4±6.6cm/秒；非排斥者为26.1±8.8cm/秒；p≤0.0001）。15例患者中有10例收缩期正向血流缺失。如果将急性排斥反应定义为收缩期正向血流≤17cm/秒，那么敏感性为100%，特异性为80%，预测准确性为90%。
与非排斥者相比，急性心脏排斥反应期间上腔静脉收缩期正向血流明显减少。这伴有其他与“限制性”生理学发展一致的多普勒超声心动图特征。据推测，上腔静脉收缩期正向血流丧失是由于与急性心脏排斥反应相关的右心室长轴缩短减少所致。
