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Theefficacyofelectrocardiographyin
detectingacuterejectioninpediatricheart
transplantrecipients
¡  Acuteallograftrejectionisanimportant
problemforhearttransplantrecipients.
¡  Endomyocardialbiopsyisthemostreliable
butinvasivemethodtodetectacute
rejection.
¡  WeaimedtodetectefficacyofECGtohelp
diagnosisofacuterejection.
¡  37patientsundergoingorthotopicheart
transplantationbetween2005-2016are
included.
¡  Data
§  Presenceofrejectioninthebiopsies
§  Echocardiographyresultsand
§  ECGrecordingsduringadmissionforbiopsyand
onsuspicionforrejectionareevaluated.
¡  ECGdata
§  PR,QRS,QTcperiod
§  QRSaxis
§  Heartrate
§  STsegmentandTwaveabnormalities
§  Ventricularhypertrophy
§  Conductionblock
§  Voltagesuppresion,and
§  Dysrhythmiawerenoted.
¡  Meanageatthetimeoftransplantationwas
11.9y(11months-19years).
¡  Cardiacdiagnoses
§  dilatedcardiomyopathy §  restrictivecardiomyopathy
§  congenitalheartdisease §  chemotherapy-relatedcardiomyopathy
§  hypertrophiccardiomyopathy §  arrhythmogenicrightventriculardysplasia
15
12
4
2
1
1
¡ 
Figure.Distributionof252biopsiesscoredbytheInternational
SocietyforHeartandLungTransplantation(ISHLT)guidelines
[Stewart2005].Grade0R=norejection;grade1R=mild;grade2R=
moderate;grade3R=severerejection.
Norejec(on
Grade1R
Grade2R
Acutehumoral S u s p e c t e d
humoral
PR(msec)
QRS(msec)
QTc(msec)
Heartrate
(beat/min)
142.7
73.2
420.6
99.5
130.7
146.6
130.8
145.2
(p:0.117)
(p:0.60)
(p:0.05)
(p:0.68)
64.1
51.6
72.4
64.7
(p:0.05)
(p:0.016)
(p:0.90)
(p:0.24)
426.3
417
423.8
435.5
(p:0.38)
(p:0.76)
(p:0.74)
(p:0.14)
108.1
110
113.8
104.2
(p:0.03)
(p:0.14)
(p:0.18)
(p:0.42)
ST
STdepression
eleva(on
VHT
Arrythmia
Twave
suppression N(%)
N(%) N(%) N(%)
N(%)
N(%)
2mm 1mm
2mm
N(%)
N(%) N(%)
N(%)
2
10
4
29
2
8
(5)
(2)
(14.4)
(1)
(43.6) (2.5) (6.5) (3)
3
13
2
1
(4.2)
(37.5) (2.1) (8.4) (2)
(4.5) (1)
Rejec(on 2
(+)
LBBB
1mm
Rejec(on 9
(-)
N e g a ( v e V o l t a g e RBBB
1 12
(4.2) (2.1) (25)
p:0.034
(6.3) (27.1)*
8 5
8 1
1
4
3 6
1
¡  Ventricularand
supraventricular
tachycardia
Routinefollow-upvisit
Nocomplaint
Tachycardiaandpretibialedema
Echo:Ejectionfraction31%,shoteningfraction
16%
¡  ECG:voltagesuppresion
¡  Headmittedthathedidnottakemedications
last2weeks
¡  At6thdayoftreatment,biopsyshowedno
rejectionalthoughechoandECGwerestill
abnormal
¡ 
¡ 
¡ 
¡ 
Ejectionfraction31%,shoteningfraction16%
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§  Themostprevalentabnormality:completeor
incompleteRBBB.NewRBBBappearedin69%ofthe
patients,mainlyduringthefirstmonth.
§  9episodesofsupraventriculararrhythmias:1atrial
fibrillation,6atrialflutter,1junctionaltachycardia
§  3ofthe6episodesofatrialflutteroccurredduringan
episodeofacuterejection
§  RBBBwasnotassociatedwithacuterejection
Clin. Cardiol. 21, 680-684 (1998)
Presentation with sinus tachycardia and lateral ST-segment elevations with
reciprocal depressions in inferior leads
.
Circ Heart Fail. 2015;8:836-838
On hospital day #5 ECG demonstrating resolved ST-segment elevations
Circ Heart Fail. 2015;8:836-838
¡  RoutineECGfollow-upofpatientswithOHT
waspreviouslyshowntohelpdetectacute
rejection.
¡  OurstudysupportsthepowerofECGto
demonstrateabnormalitiesevenin
asymptomaticpatientsandinthosewith
normalbiopsybutwithclinicalevidenceof
acuterejection.
¡  SerialECGsareimportanttodepict
deteriorations
¡  STdepressionorelevation
¡  Twaveinversion
¡  Voltagesuppression
¡  Newonsetarrythmiaespeciallyafterthefirst
3monthsshouldalertforacuterejection