Smart F W, Ballantyne C M, Cocanougher B, Farmer J A, Sekela M E, Noon G P, Young J B
Multi-Organ Transplant Center, Methodist Hospital, Houston, Texas 77030.
Am J Cardiol. 1991 Feb 1;67(4):243-7. doi: 10.1016/0002-9149(91)90553-w.
Obstructive coronary artery vasculopathy can be a major problem after cardiac transplant. The use of noninvasive tests to detect coronary artery vasculopathy was studied in 73 consecutive patients after heart transplant. Angiographically or autopsy-proved coronary artery disease was noted in 19 consecutive patients (26%) followed prospectively for 2.5 +/- 1.3 years (mean +/- standard deviation). Patients underwent yearly surveillance echocardiographic, rest/exercise-gated wall motion, oral dipyridamole thallium, ambulatory electrocardiographic monitor and angiographic studies. Positive test results were defined by decrease in ejection fraction, wall motion abnormality, failure to increase ejection fraction, lack of systolic blood pressure increase, and ischemic ST changes at maximal exercise (or on ambulatory monitor). Wall motion abnormalities and depressed ejection fraction on echocardiography were also abnormal studies as were fixed or reversible perfusion defects on thallium scan. Angiograms were considered positive when 50% luminal narrowing was observed and autopsy coronary artery vasculopathy was defined as cross-sectional coronary obstruction greater than or equal to 70%. No procedure that was examined proved to be a sensitive noninvasive detector of heart transplant coronary artery vasculopathy. All except ambulatory electrocardiographic monitoring had positive predictive values less than 50%. Interestingly, of the techniques evaluated, echocardiography was most sensitive (53%). The poor predictive ability of noninvasive testing in this population may be due to the fact that these tests are designed to detect effects of ischemia rather than coronary obstruction alone. Use of these particular noninvasive modalities routinely after heart transplant to detect coronary artery vasculopathy should be reconsidered because of their low sensitivity and predictive value when used as a surveillance screen.
阻塞性冠状动脉血管病变可能是心脏移植后的一个主要问题。对73例连续心脏移植患者进行了使用非侵入性检测来发现冠状动脉血管病变的研究。在对19例连续患者（26%）进行了2.5±1.3年（平均±标准差）的前瞻性随访中，发现了经血管造影或尸检证实的冠状动脉疾病。患者每年接受监测超声心动图、静息/运动门控壁运动、口服双嘧达莫铊、动态心电图监测和血管造影研究。阳性检测结果的定义为射血分数降低、壁运动异常、射血分数未增加、收缩压未升高以及最大运动时（或动态监测时）出现缺血性ST段改变。超声心动图上的壁运动异常和射血分数降低以及铊扫描上的固定或可逆灌注缺损也属于异常研究。当观察到管腔狭窄50%时，血管造影被认为是阳性，尸检冠状动脉血管病变被定义为冠状动脉横截面积阻塞大于或等于70%。所检查的任何一种方法都未被证明是心脏移植冠状动脉血管病变的敏感非侵入性检测方法。除动态心电图监测外，所有方法的阳性预测值均低于50%。有趣的是，在所评估的技术中，超声心动图最敏感（53%）。在这一人群中非侵入性检测的预测能力较差可能是因为这些检测旨在检测缺血的影响而非仅仅冠状动脉阻塞。由于这些特定的非侵入性方法在用作监测筛查时敏感性和预测价值较低，因此应重新考虑在心脏移植后常规使用它们来检测冠状动脉血管病变。
