Doppler examination of superior vena caval flow for the detection of acute cardiac rejection.

Abstract

Doppler echocardiographic studies have previously documented abnormalities of mitral flow during acute rejection similar to those seen in patients with "restrictive" physiology. As central venous flow is known to be abnormal in such patients, it was proposed that examination of superior vena caval flow with Doppler echocardiography might be useful for the detection of acute cardiac rejection. Thirty orthotopic cardiac transplant patients, 15 of whom had acute cardiac rejection diagnosed by endomyocardial biopsy, were studied within 36 hours of biopsy. Superior vena caval Doppler flow velocities as well as mitral and tricuspid flow velocities were recorded using a Hewlett-Packard Sonos 500/1000 echocardiograph system. Examinations were performed blinded to the biopsy result. Mitral and tricuspid peak early flow velocities in the nonrejector group were similar to those seen in normal subjects (mitral, 70 +/- 5 cm/sec; tricuspid midexpiratory apnea, 50 +/- 11 cm/sec). Superior vena caval flow was abnormal with 13 of 15 patients demonstrating a biphasic pattern of forward flow with dominant diastolic flow. In the 15 patients with acute cardiac rejection, both mitral and tricuspid flow velocities developed a "restrictive"-type pattern with increased peak early flow velocities (mitral, 89 +/- 24 cm/sec; tricuspid midexpiratory apnea, 63 +/- 19 cm/sec; p < or = 0.05 versus nonrejectors) and decreased mitral early flow-velocity deceleration times (rejectors, 97 +/- 26 msec; nonrejectors, 144 +/- 41 msec; p < or = 0.05). The pattern of superior vena caval flow became markedly abnormal with a virtually complete loss of forward systolic flow (rejectors, 4.4 +/- 6.6 cm/sec; nonrejectors, 26.1 +/- 8.8 cm/sec at midexpiratory apnea; p < or = 0.0001). In 10 of 15 patients, systolic forward flow was absent. If acute rejection was defined as forward systolic flow < or = 17 cm/sec, then sensitivity was 100%, specificity was 80%, and predictive accuracy was 90%. During acute cardiac rejection, forward systolic superior vena caval flow is markedly diminished compared with nonrejectors. This is accompanied by other Doppler echocardiographic features consistent with the development of "restrictive" physiology. It is postulated that the loss of forward systolic flow in the superior vena cava is due to diminished long-axis shortening of the right ventricle associated with acute cardiac rejection.