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Invasive methods as coronary angiography and intravascular ultrasound (IVUS) are still the routine tools for diagnosis of cardiac allograft vasculopathy (CAV). Nevertheless, invasive tests are expensive and not free of risk. Dobutamine stress echocardiography (DSE) emerged as a useful noninvasive tool for assessment of cardiac allograft vasculopathy (CAV). In our study, echocardiographic wall motion abnormalities (WMA) at rest had a sensitivity of 57% (specificity 88%) to detect CAV defined by IVUS and angiography, which was significantly (p < 0.0001) improved to 72% (specificity 88%) by stress testing. Additional M-mode analysis of systolic wall thickening improved the sensitivity of the resting echocardiogram to 72% (specificity 85%), the combined M-mode and 2D-analysis during stress had a sensitivity of 85% (p < 0.0001; specificity 82%). DSE was also useful to predict prognosis: 1.9% of patients with normal, but 27.3% of patients with abnormal 2D-DSE developed cardiac events (heart failure, infarction, death, re-HTX, PTCA) between annual studies (p < 0.0002). No change in serial DSE studies was associated with a low event rate (4%), compared to serial DSE deterioration (29%, p < 0.0014). Based on our experience, we postpone invasive studies for 12-24 months, if DSE is normal or remains unchanged in serial studies. Angiography is used in patients with abnormal or deteriorating DSE. In conclusion, noninvasive DSE provides useful diagnostic and prognostic information. It appears safe to use DSE as a first step of CAV monitoring.

Unlabelled: Stress echocardiography has been shown to be a valuable noninvasive method for the diagnosis of restenosis after coronary angioplasty. To determine the usefulness of dobutamine stress echocardiography (DSE) for assessment of restenosis after intracoronary stent implantation, we studied 50 patients (59+/-10 years; 1-vessel disease, n=16; multivessel disease, n=34) after stent implantation. After 6 month, both DSE (5-40 mcg/kg/min, 0-1mg atropine) and angiography were performed within 48 hours and evaluated in a blinded fashion. Restenosis was defined by quantitative coronary angiography as minimal lumen diameter (LD) <50% of average reference LD. Diagnostic criteria of DSE were new or worsening wall motion abnormalities in corresponding perfusion territories during stress. Angiography revealed restenosis in 8 patients; one patient had a denovostenosis distal to the stented segment (8 x left anterior descending artery, 1 ACVB to the right coronary artery). In 6 of these 9 patients, DSE was positive (mean reduction of LD 88+/-7%; sensitivity 67%), in 3 patients negative (mean reduction of LD 62+/-7%, 1 x termination of DSE because of wall motion abnormalities in an area not supplied by the stented vessel). In 38 of 41 patients without restenosis, DSE showed no stress-induced wall motion abnormalities in the LV area supplied by the stented vessel (specificity 93%)., Conclusions: DSE is a useful noninvasive method for detecting restenosis after intracoronary stent implantation. With negative DSE at follow-up, a functionally relevant stent restenosis is highly unlikely.

Background: Coronary angiography is still the routine screening method for cardiac allograft vasculopathy in most transplant centers. This study was designed to analyze functional and morphologic changes in heart transplant recipients with normal angiographic findings., Methods: Dobutamine stress echocardiography and intracoronary ultrasound were obtained in 56 patients with a normal coronary angiogram 41+/-31 months after heart transplantation. Intracoronary Doppler flow velocity measurements before and after intracoronary adenosine administration were performed in 34 of 56 patients. Any regional wall motion abnormalities detected by stress echocardiography were regarded as abnormal. By quantitative intracoronary ultrasound analysis using a 6-grade scale, a mean grade of all coronary segments >3.0 was defined as significant intimal hyperplasia., Results: Only 17 patients (30%) showed both a normal dobutamine stress echocardiogram and absence of significant intimal hyperplasia by intravascularultrasound. Abnormal findings were observed in 39 patients (70%): both by dobutamine stress echocardiography and intravascular ultrasound in 22 patients, by intravascular ultrasound alone in 11 patients, and by dobutamine stress echocardiography alone in 6 patients. Coronary flow velocity reserve did not discriminate between patients with normal or abnormal intravascular ultrasound or dobutamine stress echocardiographic findings., Conclusions: Only a minority of heart transplant patients with a normal coronary angiogram is free of pathological changes, when assessed by intravascular ultrasound and dobutamine stress echocardiography. Coronary flow velocity reserve does not seem useful to further characterize these patients.

Cardiac allograft vasculopathy (CAV) remains a major problem after heart transplantation. This prospective study was performed to analyze the value of quantitative dobutamine stress echocardiography for the diagnosis of CAV compared with coronary angiography and intravascular ultrasound (IVUS). In 80 patients late (> or = 12 months) after cardiac transplantation, a total of 144 studies were evaluated. In addition to the usually performed regional wall motion analysis of 2D-echocardiograms, systolic thickening of septum and left ventricular posterior wall was quantified by M-mode echocardiography. In patients with CAV by invasive angiography and/or IVUS, systolic thickening of the septum and posterior wall was significantly lower at rest and at maximum dobutamine infusion than in patients without CAV. From a subgroup of 23 studies in transplant recipients without TVP or other cardiac complications, normal values for the M-mode parameters were calculated. The lower limits were: systolic thickening of septum at rest, > 17.2%, at maximum stress, > 45.9%; systolic thickening of left ventricular posterior wall at rest, > 41.6%, at maximum stress, > 67.6%. Regional wall motion analysis of 2D-echocardiograms had a sensitivity of 76% (specificity 82%) for diagnosis of CAV defined by invasive methods, evaluation of wall thickening by M-mode alone had a sensitivity of 63% (specificity 76%). The combined 2D- and M-mode-echocardiographic analysis yielded a sensitivity of 85% (specificity 71%). In summary, dobutamine stress echocardiography is a useful method for the noninvasive diagnosis of CAV. The quantitative M-mode analysis improves the sensitivity of the 2D-analysis. The calculated normal values for the M-mode parameters in heart transplant recipients may serve as reference for other studies.