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(Circulation. 2006;114:I-49 – I-55.)
© 2006 American Heart Association, Inc.

Cardiac Transplantation and Surgery for Congestive Heart Failure

Coronary Flow Velocity Pattern and Coronary Flow Reserve by Contrast-Enhanced Transthoracic Echocardiography Predict Long-Term Outcome in Heart Transplantation

Francesco Tona, MD, PhD; Alida L.P. Caforio, MD, PhD; Roberta Montisci, MD; Antonio Gambino, MD; Annalisa Angelini, MD; Massimo Ruscazio, MD; Giuseppe Toscano, MD; Giuseppe Feltrin, MD; Angelo Ramondo, MD; Gino Gerosa, MD; Sabino Iliceto, MD

From Department of Cardiology (R.M.), University of Cagliari, Cagliari, Italy; Departments of Cardiology (F.T., A.L.P.C., M.R., A.R., S.I.), Pathology (A.A.), and Cardiovascular Surgery (A.G., G.F., G.G., G.T.); University of Padova, Padova, Italy.

Correspondence to Francesco Tona, MD, PhD, Division of Cardiology, Department of Cardiological, Thoracic, and Vascular Sciences, Centro "V. Gallucci", University of Padova-Policlinico, Via Giustiniani, 2, 35128 Padova, Italy. E-mail francescotona{at}hotmail.com

Background— We assessed coronary flow velocity pattern and coronary flow reserve (CFR) by contrast-enhanced transthoracic echocardiography (CE-TTE) as markers of major adverse cardiac events (MACE) related to cardiac allograft vasculopathy (CAV) after heart transplantation (HT).

Methods and Results— Deceleration time of diastolic flow velocity (DDT) and CFR were measured in the left anterior descending coronary artery (LAD) by CE-TTE in 66 consecutive HT patients (follow-up 19±5 months). CFR was calculated as the ratio of hyperemic to basal diastolic flow velocity. Angiographies were analyzed by a qualitative grading system; CAV was defined as changes grade II or higher. MACE were cardiac death, stent implantation, and heart failure. Patients with MACE had higher CAV incidence (P=0.004) and grade (P=0.008), shorter DDT (P=0.006), and lower CFR (P=0.008). A receiver-operating characteristic–derived DDT cutpoint 840 ms (area under the curve 0.793; P=0.01) was 75% specific and 86% sensitive for predicting MACE, with positive predictive value (PPV) and negative predictive value (NPV) of 33% and 97%, respectively (P=0.002). A CFR cutpoint of 2.6 (area under the curve 0.746; P=0.01) was 62% specific and 91% sensitive for predicting MACE (PPV =32%, NPV =97%) (P=0.001). Patients with CFR 2.6 and patients with DDT 840 ms had a lower survival free from MACE (P=0.006 and P=0.009, respectively). By Cox regression, only a lower CFR predicted the risk of MACE (relative risk 3.1; 95% CI, 1.26 to 7.9; P=0.01).

Conclusions— In HT patients, shorter DDT and lower CFR by CE-TTE are reliable markers for CAV-related MACE. CFR is the main independent predictor of MACE.

Key Words: cardiac allograft vasculopathy • coronary flow reserve • heart transplantation