Diagnostic Accuracy of Dobutamine Stress Echocardiography for Detection of Cardiac Allograft Vasculopathy in Orthotopic Heart Transplant Patients

Abstract

Objective Cardiac allograft vasculopathy is one of the leading causes of late graft failure and subsequent death in orthotopic heart transplant. Although invasive coronary angiography is the gold standard modality for detection of cardiac allograft vasculopathy, dobutamine stress echocardiography has been recently frequently used as an alternative. Our aim was to evaluate the diagnostic performance of dobutamine stress echocardiography for detection of cardiac allograft vasculopathy in transplant patients. Methods A retrospective analysis was conducted using a total of 150 dobutamine stress echocardiographic exams that were performed on 99 patients in our institution, with paired coronary angiogram and no acute rejection, within a median of 538 [interquartile range 371–816] days. Sensitivity and specificity of dobutamine echocardiography to detect allograft vasculopathy was evaluated. Allograft vasculopathy was defined as Grade 1 or higher based on ISHLT criteria. A positive dobutamine stress echo result was defined by new or worsening wall motion abnormality. Results Median age of the population at transplant was 34 [interquartile range 22–46] years; 76 (77%) patients were male. Allograft vasculopathy was present in 31 (20.6%) out of 150 coronary angiograms. Only 7 (4.6%) of that number were positive on dobutamine stress echocardiography. Sensitivity and specificity for allograft vasculopathy detection was 3% and 94%, respectively. Out of 7 false positive dobutamine stress echocardiograms, two were in patients with myocardial bridging. Two patients with mild acute rejection had both negative dobutamine stress echo. Conclusions Overall, positivity of dobutamine stress echocardiography in patients after heart transplant is low. It has high specificity, but very low sensitivity for detection of cardiac allograft vasculopathy. Dobutamine stress echocardiography should only be cautiously used as an alternative to coronary angiography.

A Comprehensive Excursus of the Roles of Echocardiography in Heart Transplantation Follow-Up

“…Dobutamine stress echocardiography (DSE) has been the most widely used non-invasive tool to detect inducible ischemia in HT patients. Even so, the diagnostic value of DSE for detection of CAV remains unclear because of the wide range in reported sensitivity and specificity [ 82 , 83 , 84 , 85 , 86 ]. In a large meta-analysis by Elkaryoni et al, the sensitivity of DSE to detect CAV varied from 1.7% to 93.8% (pooled 60.2%), and specificity from 54.8% to 98.8% (pooled 85.7%) [ 87 ].…”

New Non-Invasive Imaging Technologies in Cardiac Transplant Follow-Up: Acquired Evidence and Future Options

“…Numerous studies have evaluated the ability of dobutamine SE (DSE) to detect inducible ischemia [36][37][38][39][40]. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of DSE in diagnosing CAV range from 63% to 95%, 55% to 95%, 40% to 92%, and 62% to 92%, respectively.…”

“…The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of DSE in diagnosing CAV range from 63% to 95%, 55% to 95%, 40% to 92%, and 62% to 92%, respectively. These values vary depending on the angiographic definitions of CAV used, which can range from any angiographic abnormality to significant stenosis [37][38][39][40]. Data regarding the sensitivity and NPV of DSE to detect any stage of CAV are inconsistent, with a study by Eroglu et al showing a relatively modest sensitivity value of 63% [40].…”