← Section V · Cardiac Masses, Pericardial Disease, Contrast and New Applications

V.F

Echocardiography in Cardiac Transplantation

6 cards

Notes

Normal post-transplant echo findings

Bi-atrial anastomosis (older technique) - both atrial cuffs sutured together → globular enlarged atria on echo.
Bicaval anastomosis (modern technique) - normal atrial geometry.
Small pericardial effusion is common in first months post-op.
Right heart may appear mildly enlarged early due to elevated PVR in donor heart.
Denervated heart: HR is set by intrinsic sinus rate (~90–100), no vagal tone.

Rejection

Endomyocardial biopsy remains gold standard.
Echo signs of acute cellular rejection:
- Diastolic dysfunction (rise in E/e′, restrictive filling pattern).
- LV wall thickening (myocardial edema).
- Pericardial effusion.
- Reduction in TDI-derived indices.
Strain imaging (GLS) declines with rejection before EF changes.

Cardiac allograft vasculopathy (CAV)

Chronic diffuse coronary vasculopathy - the most common long-term cause of graft failure.
Not detected by routine coronary angiography (diffuse rather than focal); IVUS is more sensitive.
Echo: diffuse LV wall-motion abnormalities, restrictive filling patterns, RV dysfunction.
Dobutamine stress echo useful for detecting significant CAV.

Immunosuppression effects on echo

Steroids → LV mass may increase.
Cyclosporine/tacrolimus → hypertension may drive LVH.

Timing of surveillance echo

Frequent early (weekly, then monthly), then annual or event-driven long-term.

Non-rejection complications visible on echo

Pericardial effusion → tamponade physiology.
Diastolic dysfunction from ischemia or rejection.
Tricuspid regurgitation from repeated endomyocardial biopsies (chordal damage).
Cardiac tumors (post-transplant lymphoproliferative disease).

Cards

basicV.F-001
Why does a heart-transplant recipient have a resting heart rate around 90–100 bpm?
→ The transplanted heart is denervated (both vagal and sympathetic input are severed). Resting HR reflects the intrinsic sinus rate without vagal tone.
basicV.F-002
What is the atrial appearance difference between bi-atrial and bicaval anastomosis techniques for heart transplantation?
→ Bi-atrial (older): both atrial cuffs sutured together — atria appear enlarged and globular. Bicaval (modern): SVC and IVC anastomosed directly — normal atrial geometry.
basicV.F-003
What is the gold standard for diagnosing acute cellular rejection after cardiac transplantation?
→ Endomyocardial biopsy (typically obtained through the right internal jugular vein). Echo is complementary but not definitive.
basicV.F-004
Give three echo findings that may suggest rejection.
→ 1) New or worsening diastolic dysfunction (restrictive pattern, elevated E/e′). 2) LV wall thickening from myocardial edema. 3) New pericardial effusion. 4) Reduction in GLS or TDI indices before EF changes.
basicV.F-005
What is cardiac allograft vasculopathy (CAV) and how is it best detected?
→ Chronic diffuse concentric coronary vasculopathy — leading long-term cause of graft failure. Intravascular ultrasound (IVUS) is more sensitive than angiography because the disease is diffuse rather than focal. Dobutamine stress echo detects significant CAV noninvasively.
basicV.F-006
What valvular complication commonly develops from repeated endomyocardial biopsies?
→ Tricuspid regurgitation from chordal or leaflet damage during biopsy catheter passage.