We identified 11 patients who underwent heart transplantation between 2002 and 2012 and were treated for BNR. One of the 11 patients was treated a second time for BNR.
The immunosuppression regimen at time of BNR onset is shown in Table 2.
The remaining 5 cases (in 5 patients, including 1 patient's second case of BNR) maintained persistent left ventricular dysfunction beyond 90 days.
In summary, the LVEF status at 90 days is as follows: 5 cases (in 5 patients, including 1 case as second BNR on a patient) had persistent LV dysfunction, and 7 cases (in 7 patients) experienced normalized LVEF.
The concept of BNR has evolved from its initial definition as hemodynamic compromise in the absence of acute cellular rejection to its current definition of patients presenting with cardiac dysfunction in the absence of biopsy findings of cellular rejection or AMR .
Due to the inconsistencies of endomyocardial biopsies, the existence of BNR is questioned.
Although clinical applications have not been implemented, CMR was demonstrated to be capable of providing the rejection status of whole-heart perspective, and thus might be a potential tool of optimizing diagnosis of BNR. Another potential tool is speckle-tracking 2-dimensional strain echocardiography (2DSE).
Perhaps BNR is another form of AMR but due to the "newness" of AMR and the lack of a complete understanding of AMR, no definite conclusions can be made .
This revised definition of BNR has been noted to result in a decrease in 3-year subsequent survival, lower subsequent freedom from cardiac allograft vasculopathy (CAV), and a decrease in freedom from nonfatal major adverse cardiac events (NF-MACE) .
A point of interest in this study is the patient who experienced two episodes of BNR. Due to the small sample size, it is uncertain whether having one episode of BNR increases the risk of recurrent BNR episodes.
The repeat BNR patient was the only African Americans in this study and did not experience normalized LVEF at 90-day after second onset.