Echocardiography in Heart Transplantation

  • Nehzat Akiash
  • Anita Sadeghpour
  • Azin Alizadehasl


Orthotopic Heart Transplantation (OHT) is an appropriate treatment for patients with end-stage heart failure, as the beating heart is taken from a donor and will implanted in the normal place of the recipient who has a high chance for post-transplantation recovery, improvement in quality of life, and survival. In recent decades, significant progress has been made in measures needed to control and assess transplant rejection and post-transplantation infections (Stengel et al., Heart 86(4):432–437, 2001).

The first heart transplant surgery technique, described by Shumway, Lower, and Stofer, is known as biatrial anastomosis technique (BAAT) (Bolman, Oper Tech Thorac Cardiovasc Surg 4(2):98–113, 1999; Kitamura et al., Circ J 73(7):1235–1239, 2009), which was later replaced by bicaval anastomosis technique (BCAT) (Locali et al., Arq Bras Cardiol 94(6):829–840, 2010). Other methods such as modified bicaval anastomosis technique (mBCAT) were developed by a group of Japanese heart surgeons as an appropriate heart transplant method (Bolman, Oper Tech Thorac Cardiovasc Surg 4(2):98–113, 1999). In first year after OHT, graft rejection and infections are more common cause of death, and often allograft vasculopathy and malignancy occur 5 year after cardiac transplant, whereas survival rate of patients following OHT has shown dramatic progress due to advances in surgical methods and improvements in management of patients after OHT.


Echocardiography Heart transplantation Biatrial anastomosis technique Bicaval anastomosis technique Coronary artery disease Cardiac allograft vasculopathy Doppler tissue imaging 





Two-dimensional echocardiography




Three-dimensional echocardiography


Biatrial anastomosis technique


Bicaval anastomosis technique


Coronary artery disease


Cardiac allograft vasculopathy


Doppler tissue imaging


Ejection fraction


Heart failure


Heart transplantation




Isovolumic relaxation time


Intravascular ultrasound


Left atrial


Left ventricular


Orthotopic heart transplantation


Pulmonary hypertension


Pulmonary vascular resistant


Right atrial


Right ventricular


Tissue Doppler imaging


Tumor necrosis factor-α


Tricuspid regurgitation


Transthoracic echocardiography

Supplementary material

Movie 34.1

Heterotopic heart transplantation, 4-chamber view of recipient and short axis view of donor heart (AVI 9486 kb)

Movie 34.2

Heterotopic heart transplantation, recipient and donor left atrial anastomosis (AVI 10483 kb)

Movie 34.3

Heterotopic heart transplantation, color Doppler study of recipient and donor left atrial anastomosis (AVI 3385 kb)


  1. 1.
    Kadner A, Chen RH, Adams DH. Heterotopic heart transplantation: experimental development and clinical experience. Eur J Cardiothorac Surg. 2000;17(4):474–81.CrossRefPubMedGoogle Scholar
  2. 2.
    Davies RR, Russo MJ, Morgan JA, Sorabella RA, Naka Y, Chen JM. Standard versus bicaval techniques for orthotopic heart transplantation: an analysis of the United Network for Organ Sharing database. J Thorac Cardiovasc Surg. 2010;140(3):700–8, 8.e1-2.CrossRefPubMedGoogle Scholar
  3. 3.
    Mann D, Zipes D, Libby P, Bonow R. Braunwald’s heart disease: a textbook of cardiovascular medicine, Single Volume. 10th ed. Philadelphia: Elsevier/Saunders; 2014. p. 2040.Google Scholar
  4. 4.
    Mondillo S, Maccherini M, Galderisi M. Usefulness and limitations of transthoracic echocardiography in heart transplantation recipients. Cardiovasc Ultrasound. 2008;6:2.CrossRefPubMedGoogle Scholar
  5. 5.
    Stehlik J, Edwards LB, Kucheryavaya AY, Benden C, Christie JD, Dipchand AI, et al. The Registry of the International Society for Heart and Lung Transplantation: 29th official adult heart transplant report—2012. J Heart Lung Transplant. 2012;31(10):1052–64.CrossRefPubMedGoogle Scholar
  6. 6.
    Costanzo MR, Augustine S, Bourge R, Bristow M, O’Connell JB, Driscoll D, et al. Selection and treatment of candidates for heart transplantation. A statement for health professionals from the Committee on Heart Failure and Cardiac Transplantation of the Council on Clinical Cardiology, American Heart Association. Circulation. 1995;92(12):3593–612.CrossRefPubMedGoogle Scholar
  7. 7.
    Brock MV, Salazar JD, Cameron DE, Baumgartner WA, Conte JV. The changing profile of the cardiac donor. J Heart Lung Transplant. 2001;20(9):1005–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Venkateswaran RV, Bonser RS, Steeds RP. The echocardiographic assessment of donor heart function prior to cardiac transplantation. Eur J Echocardiogr. 2005;6(4):260–3.CrossRefPubMedGoogle Scholar
  9. 9.
    Sopko N, Shea KJ, Ludrosky K, Smedira N, Hoercher K, Taylor DO, et al. Survival is not compromised in donor hearts with echocardiographic abnormalities. J Surg Res. 2007;143(1):141–4.CrossRefPubMedGoogle Scholar
  10. 10.
    Kilic A, Emani S, Sai-Sudhakar CB, Higgins RSD, Whitson BA. Donor selection in heart transplantation. J Thorac Dis. 2014;6(8):1097–104.PubMedCentralPubMedGoogle Scholar
  11. 11.
    Wever Pinzon O, Stoddard G, Drakos SG, Gilbert EM, Nativi JN, Budge D, et al. Impact of donor left ventricular hypertrophy on survival after heart transplant. Am J Transplant. 2011;11(12):2755–61.CrossRefPubMedGoogle Scholar
  12. 12.
    Kettner J, Dorazilova Z, Netuka I, Maly J, Al-Hiti H, Melenovsky V, et al. Is severe pulmonary hypertension a contraindication for orthotopic heart transplantation? Not any more. Physiol Res. 2011;60(5):769–75.PubMedGoogle Scholar
  13. 13.
    Temporelli PL, Scapellato F, Eleuteri E, Imparato A, Giannuzzi P. Doppler echocardiography in advanced systolic heart failure: a noninvasive alternative to Swan-Ganz catheter. Circ Heart Fail. 2010;3(3):387–94.CrossRefPubMedGoogle Scholar
  14. 14.
    Otto CM. The practice of clinical echocardiography. 5th ed. Philadelphia: Saunders; 2017. p. 577–95.Google Scholar
  15. 15.
    Kuppahally SS, Michaels AD, Tandar A, Gilbert EM, Litwin SE, Bader FM. Can echocardiographic evaluation of cardiopulmonary hemodynamics decrease right heart catheterizations in end-stage heart failure patients awaiting transplantation? Am J Cardiol. 2010;106(11):1657–62.CrossRefPubMedGoogle Scholar
  16. 16.
    Stetson SJ, Perez-Verdia A, Mazur W, Farmer JA, Koerner MM, Weilbaecher DG, et al. Cardiac hypertrophy after transplantation is associated with persistent expression of tumor necrosis factor-alpha. Circulation. 2001;104(6):676–81.CrossRefPubMedGoogle Scholar
  17. 17.
    Angermann CE, Spes CH, Willems S, Dominiak P, Kemkes BM, Theisen K. Regression of left ventricular hypertrophy in hypertensive heart transplant recipients treated with enalapril, furosemide, and verapamil. Circulation. 1991;84(2):583–93.CrossRefPubMedGoogle Scholar
  18. 18.
    Corcos T, Tamburino C, Léger P, Vaissier E, Rossant P, Mattei M-F, et al. Early and late hemodynamic evaluation after cardiac transplantation: a study of 28 cases. J Am Coll Cardiol. 1988;11(2):264–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Mann DL, Zipes DP, Libby P, Bonow RO. Braunwald’s heart disease: a textbook of cardiovascular medicine. 10th ed. Philadelphia: Saunders; 2014. p. 575–88.Google Scholar
  20. 20.
    Stengel SM, Allemann Y, Zimmerli M, Lipp E, Kucher N, Mohacsi P, et al. Doppler tissue imaging for assessing left ventricular diastolic dysfunction in heart transplant rejection. Heart. 2001;86(4):432–7.CrossRefPubMedGoogle Scholar
  21. 21.
    Bellenger NG, Marcus NJ, Davies C, Yacoub M, Banner NR, Pennell DJ. Left ventricular function and mass after orthotopic heart transplantation: a comparison of cardiovascular magnetic resonance with echocardiography. J Heart Lung Transplant. 2000;19(5):444–52.CrossRefPubMedGoogle Scholar
  22. 22.
    Mingo-Santos S, Monivas-Palomero V, Garcia-Lunar I, Mitroi CD, Goirigolzarri-Artaza J, Rivero B, et al. Usefulness of two-dimensional strain parameters to diagnose acute rejection after heart transplantation. J Am Soc Echocardiogr. 2015;28(10):1149–56.CrossRefPubMedGoogle Scholar
  23. 23.
    Sera F, Kato TS, Farr M, Russo C, Jin Z, Marboe CC, et al. Left ventricular longitudinal strain by speckle-tracking echocardiography is associated with treatment-requiring cardiac allograft rejection. J Card Fail. 2014;20(5):359–64.CrossRefPubMedGoogle Scholar
  24. 24.
    Lu W, Zheng J, Pan X, Sun L. Diagnostic performance of echocardiography for the detection of acute cardiac allograft rejection: a systematic review and meta-analysis. PLoS One. 2015;10(3):e0121228.CrossRefPubMedGoogle Scholar
  25. 25.
    Thorn EM, de Filippi CR. Echocardiography in the cardiac transplant recipient. Heart Fail Clin. 2007;3(1):51–67.CrossRefPubMedGoogle Scholar
  26. 26.
    Aziz T, Burgess M, Khafagy R, Hann AW, Campbell C, Rahman A, et al. Bicaval and standard techniques in orthotopic heart transplantation: medium-term experience in cardiac performance and survival. J Thorac Cardiovasc Surg. 1999;118(1):115–22.CrossRefPubMedGoogle Scholar
  27. 27.
    Wong RC, Abrahams Z, Hanna M, Pangrace J, Gonzalez-Stawinski G, Starling R, et al. Tricuspid regurgitation after cardiac transplantation: an old problem revisited. J Heart Lung Transplant. 2008;27(3):247–52.CrossRefPubMedGoogle Scholar
  28. 28.
    Kalra N, Copeland JG, Sorrell VL. Tricuspid regurgitation after orthotopic heart transplantation. Echocardiography. 2010;27(1):1–4.CrossRefPubMedGoogle Scholar
  29. 29.
    Wilhelmi M, Pethig K, Wilhelmi M, Nguyen H, Struber M, Haverich A. Heart transplantation: echocardiographic assessment of morphology and function after more than 10 years of follow-up. Ann Thorac Surg. 2002;74(4):1075–9. discussion 9.CrossRefPubMedGoogle Scholar
  30. 30.
    Chan MC, Giannetti N, Kato T, Kornbluth M, Oyer P, Valantine HA, et al. Severe tricuspid regurgitation after heart transplantation. J Heart Lung Transplant. 2001;20(7):709–17.CrossRefPubMedGoogle Scholar
  31. 31.
    Bouma W, Brugemann J, Hamer IJ, Klinkenberg TJ, Koene BM, Kuijpers M, et al. Mitral valve repair and redo repair for mitral regurgitation in a heart transplant recipient. J Cardiothorac Surg. 2012;7:100.CrossRefPubMedGoogle Scholar
  32. 32.
    Fernandez J, Babadjanov D, Farivar RS. Mitral and tricuspid valve repair 21 years after cardiac transplantation. J Thorac Cardiovasc Surg. 2010;140(1):e3–4.CrossRefPubMedGoogle Scholar
  33. 33.
    Wijburg ER, Balk AH, van Herwerden LA. Double valve repair in a transplanted heart. J Thorac Cardiovasc Surg. 1998;115(1):250–1.CrossRefPubMedGoogle Scholar
  34. 34.
    Doering LV, Hickey K, Pickham D, Chen B, Drew BJ. Remote noninvasive allograft rejection monitoring for heart transplant recipients: study protocol for the novel evaluation with home electrocardiogram and remote transmission (NEW HEART) study. BMC Cardiovasc Disord. 2012;12:14.CrossRefPubMedGoogle Scholar
  35. 35.
    Roshanali F, Mandegar MH, Bagheri J, Sarzaeem MR, Chitsaz S, Alaeddini F, et al. Echo rejection score: new echocardiographic approach to diagnosis of heart transplant rejection. Eur J Cardiothorac Surg. 2010;38(2):176–80.CrossRefPubMedGoogle Scholar
  36. 36.
    From AM, Maleszewski JJ, Rihal CS. Current status of endomyocardial biopsy. Mayo Clin Proc. 2011;86(11):1095–102.CrossRefPubMedGoogle Scholar
  37. 37.
    Nguyen CT, Lee E, Luo H, Siegel RJ. Echocardiographic guidance for diagnostic and therapeutic percutaneous procedures. Cardiovasc Diagn Ther. 2011;1(1):11–36.PubMedCentralPubMedGoogle Scholar
  38. 38.
    Smart FW, Ballantyne CM, Cocanougher B, Farmer JA, Sekela ME, Noon GP, et al. Insensitivity of noninvasive tests to detect coronary artery vasculopathy after heart transplant. Am J Cardiol. 1991;67(4):243–7.CrossRefPubMedGoogle Scholar
  39. 39.
    Guddeti RR, Matsuo Y, Matsuzawa Y, Aoki T, Lennon RJ, Lerman LO, et al. Ischemic cardiomyopathy is associated with coronary plaque progression and higher event rate in patients after cardiac transplantation. J Am Heart Assoc. 2014;3(4):e001091.CrossRefPubMedGoogle Scholar
  40. 40.
    Spes CH, Klauss V, Rieber J, Schnaack SD, Tammen AR, Uberfuhr P, et al. Functional and morphological findings in heart transplant recipients with a normal coronary angiogram: an analysis by dobutamine stress echocardiography, intracoronary Doppler and intravascular ultrasound. J Heart Lung Transplant. 1999;18(5):391–8.CrossRefPubMedGoogle Scholar
  41. 41.
    Spes CH, Mudra H, Schnaack SD, Klauss V, Reichle FM, Uberfuhr P, et al. Dobutamine stress echocardiography for noninvasive diagnosis of cardiac allograft vasculopathy: a comparison with angiography and intravascular ultrasound. Am J Cardiol. 1996;78(2):168–74.CrossRefPubMedGoogle Scholar
  42. 42.
    Bolman RM III. Heart Transplantation Technique. Oper Tech Thorac Cardiovasc Surg. 1999;4(2):98–113.CrossRefGoogle Scholar
  43. 43.
    Kitamura S, Nakatani T, Kato T, Yanase M, Kobayashi J, Nakajima H, et al. Hemodynamic and echocardiographic evaluation of orthotopic heart transplantation with the modified bicaval anastomosis technique. Circ J. 2009;73(7):1235–9.CrossRefPubMedGoogle Scholar
  44. 44.
    Locali RF, Matsuoka PK, Cherbo T, Gabriel EA, Buffolo E. Should biatrial heart transplantation still be performed?: a meta-analysis. Arq Bras Cardiol. 2010;94(6):829–40.CrossRefPubMedGoogle Scholar
  45. 45.
    Stehlik J, Edwards LB, Kucheryavaya AY, Aurora P, Christie JD, Kirk R, et al. The Registry of the International Society for Heart and Lung Transplantation: twenty-seventh official adult heart transplant report—2010. J Heart Lung Transplant. 2010;29(10):1089–103.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Nehzat Akiash
    • 1
  • Anita Sadeghpour
    • 2
  • Azin Alizadehasl
    • 3
  1. 1.Assistant Professor of CardiologyAtherosclerosis Research Center, Ahvaz Jundishapur University of Medical SciencesAhvazIran
  2. 2.Professor of CardiologyEchocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical ScienceTehranIran
  3. 3.Associate Professor of Cardiology, Echocardiologist, Echocardiography and Cardiogenetic Research CentersCardio-Oncology Department, Rajaie Cardiovascular Medical and Research CenterTehranIran

Personalised recommendations