Stress Echocardiography After Cardiac Transplantation

Stress echocardiography in cardiac transplantation has three main potential applications: the detection of acute rejection in the first year after cardiac transplantation; the detection of chronic rejection later after cardiac transplantation; and – last but not least – the recruitment of marginal donor hearts as a way to solve the current donor heart shortage. The three applications have a different clinical role today. Despite the ongoing efforts of old and innovative resting and stress echocardiographic techniques in predicting biopsy-proven acute rejection, endomyocardial biopsies are still regarded as the gold standard for the detection of acute allograft rejection, which is often associated with an acute reduction in coronary flow reserve of potential diagnostic value. Conversely, stress echocardiography is able to identify accurately cardiac graft vasculopathy and has a recognized prognostic value in this clinical setting, where a normal stress echocardiogram by wall motion criteria justifies avoiding or delaying invasive studies. In the setting of cardiac allograft vasculopathy, the integration of coronary flow reserve to transthoracic stress echocardiography might further improve the value of the method. Finally, it is still purely investigational – albeit promising – to use bedside stress echocardiography for the appropriate selection of marginal heart donors with brain death to solve the current shortage of donor heart supply.