ABC | Volume 114, Nº4, April 2020

Original Article Carrion et al. Right ventricular dysfunction and heart transplant Arq Bras Cardiol. 2020; 114(4):638-644 In addition, the early post-Htx period is a time of adaptation of the new heart to the thoracic space, in a different position in the chest compared to the native heart, with expected structural alterations like increase of LV mass and in wall thickness due to inflammatory cell infiltration and graft edema, which are part of the physiological process of Htx. These abnormalities improve gradually within the first 6 months after transplant, but they can be a confounders of some signs of graft rejection. Furthermore, in agreement with the findings of our study, LV hypertrophy and changes in diastolic function, especially in LV filling pressure, have been associated with cellular rejection, despite the lower sensitivity of these findings, which may be confused with usual post-HTx alterations. 15,18 Some limitations of this analysis should be noted. As most echocardiographies for which corresponding biopsies were available had been performed to detect complications of endomyocardial biopsy, such as pericardial effusion and tricuspid valve injury, many failed to include a detailed evaluation of cardiac function and dynamics. As a consequence, we had to exclude 34% of biopsies. The single-center design of this study is also a limitation, especially because it was performed at a facility that is still expanding its HTx program, which accounts for the small sample size. Information on antibody-mediated rejection was not included in this study; therefore, echocardiographic findings cannot be extrapolated for that situation. Overall, the study comprised a low immunological risk population. Conclusions In conclusion, we found evidence of RV systolic dysfunction in post-HTx patients with moderate rejection by 2D STE assessment of strain, as well as by conventional echocardiographic methods, in comparison with patients with no significant signs of rejection on histopathology. LV systolic function remained unchanged, suggesting that subclinical LV dysfunction may arise later than RV dysfunction. Moreover, patients with biopsy evidence of moderate rejection had greater LV hypertrophy and worse LV diastolic function and filling pressure on echocardiography. The role of these findings in screening for and diagnosing rejection, perhaps even leading to practice-changing updates in endomyocardial biopsy protocols, has yet to be explored in a prospective multicenter study. Author contributions Conception and design of the research and Analysis and interpretation of the data: Carrion LFBM, Rohde LE, Santos ABS; Acquisition of data, Statistical analysis and Writing of the manuscript: Carrion LFBM, Santos ABS; Critical revision of the manuscript for intellectual content: Sperotto A, Nazario R, Goldraich LA, Clausell N. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This article is part of the thesis of master submitted by Luciana J. B. M. Carrion, from Universidade Federal do Rio Grande do Sul. Ethics approval and consent to participate This study was approved by the Ethics Committee of the UFRGS – Hospital de Clínicas de Porto Alegre under the protocol number CAAE 68562717.9.0000.5327. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. 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