Vallée Aurélien, Houyel Lucile, To Ngoc Tram, Fels Audrey, Kloeckner Martin, Blanchard David, Lemann Thomas, Gaillard Maïra, Ramadan Ramzi, Genty Thibaut, Thomas de Montpreville Vincent, Beaussier Hélène, Chatellier Gilles, Deleuze Philippe, Haulon Stephan, Guihaire Julien
Department of Cardiac Surgery, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Le Plessis Robinson, France.
M3C-Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France.
Cardiovasc Diagn Ther. 2024 Feb 15;14(1):59-71. doi: 10.21037/cdt-23-305. Epub 2024 Jan 31.
Endomyocardial biopsies (EMB) are recommended for the detection of acute cardiac rejection (ACR) despite limited sensitivity. We report the long-term post-transplant results of Doppler echocardiography as a noninvasive alternative of routine EMB.
Two cohorts of heart transplantation (HT) recipients were chronologically defined as follows: the Dual Monitoring Cohort (DMC) from January 1990 to December 1997 included patients who underwent routine EMB and Doppler echocardiography within 24 hours for ACR surveillance; and the "Echo-First Cohort" (EFC), including patients transplanted from January 1998 to December 2018 with Doppler echocardiography as first-line approach for ACR surveillance. Echocardiographic measurements of interest were collected: early diastolic (E) wave peak velocity; pressure half time (PHT) and isovolumetric relaxation time (IVRT). Post-transplant outcomes were reviewed and the Kaplan-Meier approach was used for survival estimates. Inter-operator variability for ultrasound measurements was investigated. Data were collected from medical records from January 2019 to December 2020.
A total of 228 patients were included, 99 patients in the DMC and 129 in the EFC. Overall, 5-, 10- and 15-year survival rates were 65.4%, 55.5% and 44.1% respectively, without any significant difference between the two cohorts (log rank test, P=0.71). Echocardiography variables and EMB findings were associated with a mean area under the receiver operating characteristic curve (AUC-ROC) of 0.73 [95% confidence interval (CI): 0.54-0.91], 0.74 (95% CI: 0.54-0.94) and 0.75 (95% CI: 0.57-0.94) respectively for E wave, PHT and IVRT. IVRT and PHT were significantly decreased, and E wave significantly increased, in case of histologically proven ACR. Inter-operator variability was not significant for E wave and IVRT measurements (P=0.13 and 0.30 respectively).
Doppler echocardiography as a first-line method for surveillance of ACR did not impair long-term results after HT. These findings suggest that this non-invasive approach might be a reasonable alternative to systematic EMB, limiting risk and improving the quality of life.
尽管心内膜心肌活检（EMB）的敏感性有限，但仍被推荐用于检测急性心脏排斥反应（ACR）。我们报告了将多普勒超声心动图作为常规EMB的非侵入性替代方法的移植后长期结果。
按时间顺序将两组心脏移植（HT）受者定义如下：1990年1月至1997年12月的双重监测队列（DMC）包括在24小时内接受常规EMB和多普勒超声心动图以监测ACR的患者；“超声优先队列”（EFC）包括1998年1月至2018年12月接受移植的患者，以多普勒超声心动图作为监测ACR的一线方法。收集了感兴趣的超声心动图测量值：舒张早期（E）波峰值速度、压力减半时间（PHT）和等容舒张时间（IVRT）。回顾了移植后的结果，并采用Kaplan-Meier方法进行生存估计。研究了超声测量的操作者间变异性。数据收集自2019年1月至2020年12月的医疗记录。
共纳入228例患者，DMC组99例，EFC组129例。总体而言，5年、10年和15年生存率分别为65.4%、55.5%和44.1%，两组之间无显著差异（对数秩检验，P=0.71）。超声心动图变量和EMB结果与E波、PHT和IVRT的受试者操作特征曲线下平均面积（AUC-ROC）分别为0.73[95%置信区间（CI）：0.54-0.91]、0.74（95%CI：0.54-0.94）和0.75（95%CI：0.57-0.94）相关。在组织学证实为ACR的情况下，IVRT和PHT显著降低，E波显著增加。E波和IVRT测量的操作者间变异性不显著（分别为P=0.13和0.30）。
多普勒超声心动图作为监测ACR的一线方法不会损害HT后的长期结果。这些发现表明，这种非侵入性方法可能是系统性EMB的合理替代方法，可降低风险并改善生活质量。
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