Akosah K O, Olsovsky M, Kirchberg D, Salter D, Mohanty P K
Department of Medicine, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA 23249, USA.
Circulation. 1996 Nov 1;94(9 Suppl):II283-8.
Cardiac transplantation is an accepted treatment modality for end-stage heart failure. Coronary artery disease remains a major cause of mortality in the long term after heart transplantation. Despite the high prevalence of coronary artery disease in heart transplant recipients, currently used noninvasive tests as well as invasive tests are highly unreliable in predicting prognosis. We sought to test the hypothesis that the abnormalities induced by dobutamine stress echocardiography (DSE) may be of prognostic value in predicting acute cardiac events and mortality in heart transplant patients.
We prospectively studied 86 survivors of orthotopic heart transplantation and followed them for a mean period of 2 years after the DSE. The patients' median age was 51 +/- 10 years, and mean duration since transplant was 57.7 +/- 29 months (range, 3 to 120 months, mean +/- SD). DSE was performed by a standard protocol (dobutamine 5, 10, 20, 30, and 40 micrograms.kg-1.min-1 at 5-minute stages). DSE was defined as positive for development of new or worsening regional wall motion abnormality or failure of augmentation. Nine patients were excluded from analysis (5 because of acute allograft rejection and 4 because of poor acoustic window). Thus, data from 77 patients were analyzed. Fifty-seven of 77 (74%) had positive DSE. After 24 months of follow-up, 19 of 57 patients with abnormal DSE (33%) experienced 22 major cardiac events. In contrast, no event occurred in patients with normal DSE. Of the 19 with cardiac events, there were 7 episodes of heart failure (including 3 deaths), 4 had unstable angina, and 5 died of cardiac causes. Three patients had myocardial infarction, and 3 others died of noncardiac causes. Among the variables examined, the baseline left ventricular ejection fraction was lower (44 +/- 3.8 versus 51 +/- 1.4) and peak wall motion score index was higher (2.01 +/- 0.4 versus 1.44 +/- 0.4) in the patients group with cardiac events than in those without events.
These results suggest that DSE has significant value in predicting prognosis in post-heart transplant patients. Further studies are needed to define the role of DSE as a routine test for predicting prognosis in cardiac transplant recipients.
心脏移植是终末期心力衰竭公认的治疗方式。冠状动脉疾病仍是心脏移植术后长期死亡的主要原因。尽管心脏移植受者中冠状动脉疾病的患病率很高，但目前使用的非侵入性检查以及侵入性检查在预测预后方面极不可靠。我们试图验证这样一个假设，即多巴酚丁胺负荷超声心动图（DSE）诱发的异常情况可能对预测心脏移植患者的急性心脏事件和死亡率具有预后价值。
我们对86例原位心脏移植幸存者进行了前瞻性研究，并在DSE后对他们平均随访了2年。患者的年龄中位数为51±10岁，移植后的平均时长为57.7±29个月（范围为3至120个月，平均±标准差）。DSE按照标准方案进行（多巴酚丁胺剂量为5、10、20、30和40微克·千克⁻¹·分钟⁻¹，每5分钟一个阶段）。DSE被定义为出现新的或加重的节段性室壁运动异常或心肌增厚失败即为阳性。9例患者被排除在分析之外（5例因急性移植物排斥反应，4例因声学窗不佳）。因此，对77例患者的数据进行了分析。77例患者中有57例（74%）DSE呈阳性。随访24个月后，57例DSE异常的患者中有19例（33%）发生了22次主要心脏事件。相比之下，DSE正常的患者未发生任何事件。在发生心脏事件的19例患者中，有7例出现心力衰竭（包括3例死亡），4例发生不稳定型心绞痛，5例死于心脏原因。3例患者发生心肌梗死，另外3例死于非心脏原因。在检查的变量中，发生心脏事件的患者组的基线左心室射血分数较低（44±3.8对51±1.4），峰值室壁运动评分指数较高（2.01±0.4对1.44±0.4），而未发生事件的患者组则不然。
这些结果表明，DSE在预测心脏移植术后患者的预后方面具有重要价值。需要进一步研究来确定DSE作为预测心脏移植受者预后的常规检查的作用。
