ABC | Volume 114, Nº4, April 2020

Original Article Impaired Right Ventricular Function in Heart Transplant Rejection Luciana J. B. M. Carrion, 1 Alice Sperotto, 2 R affaela Nazario, 1,2 Livia A. Goldraich, 2 Nadine Clausell, 1,2 Luís Eduardo Rohde, 1,2 Angela Barreto Santiago Santos 1, 2 Universidade Federal do Rio Grande do Sul - PPG em Cardiologia, 1 Porto Alegre, RS – Brazil Hospital de Clínicas de Porto Alegre – Cardiologia, 2 Porto Alegre, RS – Brazil Mailing Address: Angela Barreto Santiago Santos • Hospital de Clinicas de Porto Alegre – Cardiologia - Rua Ramiro Barcelos, 2350, Sala 2061. Postal Code 90035-903, Porto Alegre, RS – Brazil E-mail: abssantos@hcpa.edu.br Manuscript received January 24, 2019, revised manuscript May 03, 2019, accepted June 05, 2019 DOI: https://doi.org/10.36660/abc.20190054 Abstract Background: The practice of screening for complications has provided high survival rates among heart transplantation (HTx) recipients. Objectives: Our aim was to assess whether changes in left ventricular (LV) and right ventricular (RV) global longitudinal strain (GLS) are associated with cellular rejection. Methods: Patients who underwent HTx in a single center (2015 – 2016; n = 19) were included in this retrospective analysis. A total of 170 biopsies and corresponding echocardiograms were evaluated. Comparisons were made among biopsy/ echocardiogram pairs with no or mild (0R/1R) evidence of cellular rejection (n = 130 and n = 25, respectively) and those with moderate (2R) rejection episodes (n=15). P-values < 0.05 were considered statistically significant Results: Most patients were women (58%) with 48 ± 12.4 years of age. Compared with echocardiograms from patients with 0R/1R rejection, those of patients with 2R biopsies showed greater LV posterior wall thickness, E/e’ ratio, and E/A ratio compared to the other group. LV systolic function did not differ between groups. On the other hand, RV systolic function was more reduced in the 2R group than in the other group, when evaluated by TAPSE, S wave, and RV fractional area change (all p < 0.05). Furthermore, RV GLS (−23.0 ± 4.4% in the 0R/1R group vs. −20.6 ± 4.9% in the 2R group, p = 0.038) was more reduced in the 2R group than in the 0R/1R group. Conclusion: In HTx recipients, moderate acute cellular rejection is associated with RV systolic dysfunction as evaluated by RV strain, as well as by conventional echocardiographic parameters. Several echocardiographic parameters may be used to screen for cellular rejection. (Arq Bras Cardiol. 2020; 114(4):638-644) Keywords: Ventricular Dysfunction, Right; Heart Transplantation; Graft Rejection; Echocardiography/methods; Strain; Speckle Tracking. Introduction Over the last five decades, heart transplantation (HTx) has become an established therapeutic option for patients with end-stage heart failure. 1,2 Improvements in surgical techniques, patient selection, immunosuppressive drugs, and post-HTx protocols have contributed to the success of this therapy and increased patient survival. 2-5 Post-HTx follow-up is focused on active screening for complications. Periodic endomyocardial biopsies can diagnose most cases of acute cellular rejection (ACR), in which patients are mostly asymptomatic, and left ventricular ejection fraction (LVEF) remains normal. 2,6 However, endomyocardial biopsy is an invasive and costly procedure with potentially serious complications. 2,7-9 The search for other methods that can screen for rejection is thus becoming increasingly important. A few studies on novel echocardiographic techniques, such as two-dimensional speckle-tracking echocardiography (2D STE), have shown that reduction of left ventricular (LV) global longitudinal strain (GLS) is associated with graft rejection, and it can be used to detect early subclinical myocardial dysfunction. However, there is no consensus in the literature in relation to the clinical applicability of GLS assessment in this scenario. 2-6,10 Furthermore, little is known about right ventricular (RV) GLS and its potential role in rejection, highlighting the research gaps in this area. 10-12 Seeking to expand current knowledge about early myocardial dysfunction and graft rejection, the present study was designed to evaluate whether changes in myocardial strain by speckle tracking are associated with ACR. Specifically, we aimed to evaluate whether reduced LV GLS and RV GLS are associated with cardiac graft rejection. Methods Study Population All adult patients (age > 18 years) who underwent HTx at the Hospital de Clínicas in Porto Alegre, Rio Grande do Sul, Brazil, between 2015 and 2016 were included in this analysis. During this period, patients received routine 638