Kalp nakli sonrası rejeksiyon tanısında intramiyokardiyal elektrogramın rolü

Akut rejeksiyon, kalp nakli sonrası oluşabilecek en önemli komplikasyonlardan biridir. Akut rejeksiyonun tanı ve tedavisinin erken dönemde yapılabilmesi greft reddini önler ve sağkalımı artırır. Bugün için akut kardiyak rejeksiyonun tanısında sağ ventrikül endomiyokardiyal biyopsisi (EMB) altın standart olarak kabul edilmektedir. Ancak uygulama tekniğinin zorluğu ve invaziv olması nedeniyle hastalar için konforlu bir yöntem olmaktan uzaktır. Biyopsi tekniği ile rejeksiyon tanısının konulamaması veya rejeksiyonun geç tanılanması sonucu nakil yapılan hastaların yaklaşık %5-6sı ilk bir yıl içinde kaybedilmektedir. Hücresel voltaj amplitüdünün intramiyokardiyal olarak ölçülmesi; kalp nakli sonrası erken dönemde akut rejeksiyon tanı ve tedavisinde noninvaziv bir yöntem olarak karşımıza çıkmaktadır.

The role of intramyocardial electrocardiogram for diagnosis of acute rejection after heart transplantation

Acute rejection is one of the critical complications of heart transplantation. Early diagnosis and treatment of acute rejection following heart transplantation prevent the graft rejection and improve the survival rate. Currently, right ventricular endomyocardial biopsy (EMB) is considered the gold standard for the diagnosis of acute cardiac rejection. However, it is far from being comfortable method for the patients due its complicated implication technique and invasive nature. About 5-6% of the patients die within the first year of heart transplantation due to undiagnosed rejection or late diagnosis using biopsy technique. Intramyocardial cellular voltage amplitude measurement can be used as a noninvasive method for the diagnosis of and treatment of early acute rejection after heart transplantation.

PDF

___

1.Andreoli TE, editor. Cecil essentials of medicine. 5th ed. Philadelphia: W.B. Saunders Company; 2001. Çeviri editörü: Çavuşoğlu H. 5. Baskı. İstanbul: Nobel Tıp Kitabevi; 2002: p. 56 -7.
2.Kırali, E. Eren E, Mataracı İ, Çevirme D. Combined orthotopic heart transplantation and prophylactic ascending aorta replacement in a Marfan patient. Turk Gogus Kalp Dama 2011;19:434-6.
3.Nwakanma LU, Shah AS, Conte JV, Baumgartner WA. Heart transplantation. In: Cohn LH, editor. Cardiac surgery in the adult. 3rd ed. New York: McGraw-Hill; 2008. p. 1539-78.
4.Foerster A, Simonsen S, Frøysaker T. Heart transplantation in Norway. Morphological monitoring of cardiac allograft rejection. A 3-year follow-up. APMIS 1988;96:14-24.
5.Bourge RC, Rodriguez ER, Tan CD. Cardiac allograft rejection. In: Kirklin JK, Young JB, McGiffin DC, editors. Heart transplantation. New York: Churchill Livingstone; 2002. p. 494-5.
6.Sandhu JS, Uretsky BF, Zerbe TR, Goldsmith AS, Reddy PS, Kormos RL, et al. Coronary artery fistula in the heart transplant patient. A potential complication of endomyocardial biopsy. Circulation 1989;79:350-6.
7.Taylor DO, Yowell RL, Kfoury AG, Hammond EH, Renlund DG. Allograft coronary artery disease: clinical correlations with circulating anti-HLA antibodies and the immunohistopathologic pattern of vascular rejection. J Heart Lung Transplant 2000;19:518-21.
8.Becker AE, Heijmans CD, Essed CE. Chronic non-ischaemic congestive heart disease and endomyocardial biopsies. Worth the extra? Eur Heart J 1991;12:218-23.
9.Sharples LD, Cary NR, Large SR, Wallwork J. Error rates with which endomyocardial biopsy specimens are graded for rejection after cardiac transplantation. Am J Cardiol 1992;70:527-30.
10.Derumeaux G, Redonnet M, Soyer R, Cribier A, Letac B. Quantitative assessment of regional systolic and diastolic velocities by color doppler myocardial imaging during acut rejection in heart transplant recipients. Proceedings of the International Submit in Doppler Tissue Imaging, Madrid, 24-25 April 1997.
11.Dandel M, Hummel M, Meyer R, Müller J, Kapell S, Ewert R, et al. Left ventricular dysfunction during cardiac allograft rejection: early diagnosis, relationship to the histological severity grade, and therapeutic implications. Transplant Proc 2002;34:2169-73.
12.Ertel W, Reichenspurner H, Hammer C, Plahl M, Lehmann M, Kemkes BM, et al. Cytoimmunologic monitoring: a method to reduce biopsyfrequency after cardiac transplantation. Transplant Proc 1985;17:204-6.
13.Fieguth HG, Haverich A, Schaefers HJ, Wahlers T, Kemnitz J. Cytoimmunologic monitoring for the noninvasive diagnosis of cardiac rejection. Transplant Proc 1987;19:2541-2.
14.Mansuroğlu D, Kırali K, Güler M, Tuncer A, Eren E, Akıncı E, et al. Kalp transplantasyonlarında red fenomeninin sitoimmünolojik monitörizasyon yöntemi ile izlenmesi. GKDC Dergisi 1998;6:369-78.
15.Hirsch MS. Herpes simplex virus. In: Mandell GL, Bennett JE, Dolin R, editors. Principles and practice of infectious diseases. 4th ed. New York: Churchill Livingstone; 1995. p. 1336-45.
16.Kirklin JK, Naftel DC, Levine TB, Bourge RC, Pelletier GB, ODonnell J, et al. Cytomegalovirus after heart transplantation. Risk factors for infection and death: a multiinstitutional study. The Cardiac Transplant Research Database Group. J Heart Lung Transplant 1994;13:394-404.
17.Grauhan O, Warnecke H, Müller J, Knosalla C, Cohnert T, Voss A, et al. Intramyocardial electrogram recordings for diagnosis and therapy monitoring of cardiac allograft rejection. Eur J Cardiothorac Surg. 1993;7:489-94.
18. Buz S, Drews T, Weng Y, Muller J, Hummel M, Loebe M, Hetzer R. Heart transplantation after mechanical circulatory support. Transplant Proc 2000;32:583-4.
19.Warnecke H, Schüler S, Goetze HJ, Matheis G, Süthoff U, Müller J, et al. Noninvasive monitoring of cardiac allograft rejection by intramyocardial electrogram recordings. Circulation 1986;74:III72-6.
20.Warnecke H, Müller J, Cohnert T, Hummel M, Spiegelsberger S, Siniawski HK, et al. Clinical heart transplantation without routine endomyocardial biopsy. J Heart Lung Transplant 1992;11:1093-102.
21.Müller J, Warnecke H, Spiegelsberger S, Hummel M, Cohnert T, Hetzer R. Reliable noninvasive rejection diagnosis after heart transplantation in childhood. J Heart Lung Transplant 1993;12:189-98.
22.Hetzer R, Potapov EV, Müller J, Loebe M, Hummel M, Weng Y, et al. Daily noninvasive rejection monitoring improves long-term survival in pediatric heart transplantation. Ann Thorac Surg 1998;66:1343-9.
23.Rosenbloom M, Laschinger JC, Saffitz JE, Cox JL, Bolman RM 3rd. Noninvasive detection of cardiac allograft rejection by analysis of the unipolar peak-to-peak amplitude of intramyocardial electrograms. Ann Thorac Surg 1989;47:407-11.
24.Jia YX, Meng X, Sun LB, Han J, Chen YT. Using intramyocardial electrograms combined with other noninvasive methods for monitoring acute rejection following human heart transplantation. Chin Med J (Engl) 2009;122:136 -9.
25.Grauhan O, Müller J, Pfitzmann R, Knosalla C, Siniawski H, Fietze E, et al. Humoral rejection after heart transplantation: reliability of intramyocardial electrogram recordings (IMEG) and myocardial biopsy. Transpl Int 1997;10:439-45.
26.Knosalla C, Grauhan O, Muller J, Pfitzmann R, Fietze E, Cohnert T, et al. Intramyocardial electrogram recordings (IMEG) for diagnosis of cellular and humoral mediated cardiac allograft rejection. Ann Thorac Cardiovasc Surg 2000;6:89-94.
27.D. Çevirme, C. Köksal, M. Balkanay, H. Sunar. Early and late neurological complications after cardiac transplantation. Koşuyolu Kalp Dergisi 2011;14:56-9