Evolution of deep venous thrombosis: a 2-year follow-up using duplex ultrasound scan and strain-gauge plethysmography.

OBJECTIVE: The development of the post-thrombotic syndrome (PTS) and recurrence of deep venous thrombosis (DVT) are not yet fully understood. The aim of the study was to identify factors that lead to the long-term complications of DVT. METHODS: In a 2-year prospective follow-up study, duplex scanning and strain-gauge plethysmography were used to evaluate DVT in relation to the development of long-term complications. Each of the 12 segments examined was assigned as a thrombosis score (TS). A total TS was calculated for each leg. Patent segments were assigned a TS = 0, noncompressible vein segments with flow TS = 1 and noncompressible vein segments without flow TS = 2. The degree of resolution of DVT and the incidence, timing, and outcome of further thrombotic events were measured during 24 months of follow-up. RESULTS: The study involved 86 legs with DVT. The 2-year follow-up was completed for 70 legs. Within 3 months, only 1% of the originally occluded proximal deep vein segments were still occluded. Between all time intervals, from month 12 to month 24, for example, thrombus regression continued in 36% of the legs and thrombus propagation continued in 27%. Multiple regression analysis revealed that an increase in age (P = .008) and proximal location of the original DVT (P = .05) was significantly related to thrombus propagation. Multiple regression analysis showed that the risk factors for clinical signs of PTS were a high venous outflow resistance after 1-month and 12-month follow-ups (P

Sternal wound complications after primary isolated myocardial revascularization: the importance of the post-operative variables.

OBJECTIVE: Select pre-, peri-, and post-operative variables, predictive for sternal wound complications (SWC), in a clinical setting. METHODS: We analyzed pre-, peri-, and post-operative data of 3815 patients who underwent a primary isolated bypass grafting. 100 patients (2.6%) had post-operative SWC. Unifactor and multifactor risk analysis, were used for statistical analysis. RESULTS: Unifactor analysis identified age (P=0.05), obesity (P=0.001), lung disease (P=0.001), extracorporeal circulation >100 min (P=0.02), graft choice (P=0.01), post-operative low cardiac output, reoperation, nephrological, pulmonary problems (P<0.001) as risk factors. Multifactor analysis, identified obesity (P=0.005), reoperation (P=0.01), nephrological (P=0.0001), pulmonary problems (P=0.001) and No-IMA-use (P=0.05) as independent predictors. Age <50 years (P=0.04) decreased the risk for SWC. There is, however, an interaction of the graft-use and the pre-operative and post-operative predictors, that can mask the precise effect of the graft-use. CONCLUSION: Reoperation, nephrological and pulmonary problems are strong predictors, obesity and age independent preoperative risk factors for sternal wound complications.

Coronary reoperations in patients with a patent internal mammary artery graft.

OBJECTIVE: Analysis of short and long term results, clinical, functional and subjective status of patients, with a patent arterial graft, after coronary reoperation (RECABG). METHODS: Perioperative and follow-up data of 71 patients, undergoing coronary reoperations (1987--8) were studied. A cross-sectional follow-up was conducted, functional evaluation by the Duke Activity Status Index (DASI), and patient's evaluation of his life situation were registered. RESULTS: Perioperative mortality was 7%. Eleven patients died during follow-up. The 12-month and 60-month survival was 96% and 80%. Event-free survival was 86% and 51%. Family doctors declared that 55/66 (83%) had benefitted from the coronary reoperations. New York Heart Association decreased significantly from 3.4 +/- 0.5 preoperative versus 1.5 +/- 0.4 postoperative. The mean DASI was 38.06 +/- 10.42. At the moment of the cross-sectional follow-up, 45/55 patients (82%) declared to have benefitted from the coronary reoperations. CONCLUSION: Improvement in New York Heart Association-class, good postoperative functional capacity, and patients positive evaluation, justify coronary reoperations in patients with a patent internal mammary artery graft.

Alterations in the peripheral circulation in patients with mild heart failure.

OBJECTIVE: In patients with severe heart failure, compensatory mechanisms fail to provide adequate blood supply to the peripheral circulation, especially when the metabolic need is increased. The aim of this study was to assess alterations in the peripheral circulation in patients with mild heart failure using ultrasound Doppler. METHODS: In 19 controls and in 11 patients with mild heart failure, Doppler spectra were recorded from the carotid, the brachial and the femoral artery at rest and, from the latter two arteries, during post-occlusive reactive hyperemia. Parameters derived from these Doppler spectra were used to make comparisons between both groups. RESULTS: At rest, the duration of the acceleration of blood was shorter in controls, the acceleration was steeper in controls and the deceleration duration was longer in controls as compared to the patients. Differences in the response to reactive hyperemia were only observed in the common femoral artery. CONCLUSIONS: In patients with mild heart failure, significant alterations in the peripheral circulation were observed especially for the femoral artery. These changes are caused by the impairment of the left ventricular function and by adjustments in the compensatory mechanism of the peripheral circulation.

[Aortocoronary bypass surgery; at least 6 months follow-up required for assessment of postoperative course]. / Aortocoronaire bypasschirurgie: voor oordeel over postoperatief beloop follow-up nodig gedurende tenminste een halfjaar.

OBJECTIVE: To determine how the mortality and morbidity after aortocoronary bypass surgery during the hospital stay correspond with those in the first 6 months after the operation. DESIGN: Prospective and retrospective. METHOD: Data of 563 patients undergoing isolated myocardial revascularization in 1998 in the Academic Hospital Nijmegen, the Netherlands, were collected on mortality and morbidity 180 days after the operation. The Parsonnet score was used to assess the operative risk of the patients. RESULTS: The patient group consisted of 422 males and 141 females, with a mean age of 64.3 years. The median Parsonnet score was 6 (range: 0-50). The mean hospital stay was 7.9 days (SD: 9.4). The hospital mortality was 3.9% (22/563). The follow-up was 100%. During the follow-up 11 patients died, 10 from cardiac causes. Six months postoperatively the mortality was 5.9% (22/563). The Kaplan-Meier curve of the survival probability rate showed a persistent decrease, mainly in the higher risk patients. Non-fatal cardiovascular events were registered in 9.6% of the surviving patients (51/530). CONCLUSION: The hospital mortality and morbidity after aortocoronary bypass surgery were considerably lower than the total postoperative mortality and morbidity during the first 6 months after the operation. For assessment of the postoperative course, systematic follow-up over 6 months is necessary.

Third-time coronary artery bypass grafting.

BACKGROUND: In this study we analyze the short- and long-term results, and the clinical, functional, and subjective status of patients after a second coronary reoperation (RE-RE-CABG). METHODS: The perioperative data of 33 consecutive patients undergoing RE-RE-CABG (1987 to 1998) were studied. Follow-up information was obtained from our follow-up databank. A cross-sectional follow-up was conducted, with additional functional evaluation by the Duke Activity Status Index (DASI), and patients' evaluations of their life situation were registered. RESULTS: Perioperative mortality was 2 of 33 patients (6%). During the follow-up (mean 51.6 months) 5 patients died. The 26 survivors showed a significant decrease in New York Heart Association class from 3.6+/-0.4 preoperatively versus 2.2+/-0.6 postoperatively. The mean Duke Activity Status Index score was 29.30+/-16.34 (range 7.22 to 48.9). In all, 18 of 26 patients (70%) were declared to have benefitted from the RE-RECABG. CONCLUSIONS: The significant improve in New York Heart Association class and good postoperative functional capacity, justified the RE-RE-CABG. However, patients must be informed about the limitations of this procedure.

Venous reflux has a limited effect on calf muscle pump dysfunction in post-thrombotic patients.

The purpose of the present study was to evaluate the relationship between calf muscle pump dysfunction (CMD) and the presence and location of valvular incompetence. Deep vein obstruction might influence CMD, and so venous outflow resistance (VOR) was measured. VOR and calf muscle pump function were measured in 81 patients, 7-13 years after venographically confirmed lower-extremity deep venous thrombosis. The supine venous pump function test (SVPT) measures CMD, and the VOR measures the presence of venous outflow obstructions, both with the use of strain-gauge plethysmography. Valvular incompetence was measured using duplex scanning in 16 vein segments of one leg. Venous reflux was measured in proximal veins using the Valsalva manoeuvre, and in the distal veins by distal manual compression with sudden release. Abnormal proximal venous reflux was defined as a reflux time of more than 1 s, and abnormal distal venous reflux as a reflux time of more than 0.5 s. No statistically significant relationship was found between the SVPT and either the location or the number of vein segments with reflux. Of the 81 patients, only nine still had an abnormally high VOR, and this VOR showed no relationship with the SVPT. In conclusion, venous reflux has a limited effect on CMD, as measured by the SVPT. The presence of a venous outflow obstruction did not significantly influence the SVPT. Duplex scanning and the SVPT are independent complementary tests for evaluating chronic venous insufficiency.

The postthrombotic syndrome in relation to venous hemodynamics, as measured by means of duplex scanning and strain-gauge plethysmography.

PURPOSE: Venous hemodynamics were evaluated in relation to the postthrombotic syndrome (PTS) 7 to 13 years after deep venous thrombosis (DVT). METHODS: The presence of flow, reflux, and compressibility of 1394 vein segments in 82 patients was assessed by means of duplex scanning. The venous outflow resistance was measured by means of strain-gauge plethysmography. The venous hemodynamics were related to the clinical severity of the PTS, characterized by the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification. RESULTS: In patients with severe clinical symptoms of PTS, the prevalence of reflux was significantly higher. There was no relationship between the severity of the PTS and the noncompressibility or the combination of reflux and noncompressibility or an increased venous resistance. By means of multiple regression analysis with the variables of age, gender, reflux, and venous resistance, age and reflux were shown to be the main contributors to the severity of PTS. Significantly more patients (64%) with severe signs of PTS had a combination of deep and superficial reflux. In each of the traceable vein segments, the mean of the CEAP classification was calculated for the vein segments with and without reflux. In the proximal superficial femoral vein (P <.001), distal superficial femoral vein (P <.05), and popliteal vein (P <.05), a significantly higher mean CEAP classification was found in the veins with reflux, whereas in the distal, long, and short saphenous veins, no such relationship was found. CONCLUSION: Most patients with severe PTS had a combination of deep and superficial reflux. Reflux in the deep proximal veins contributes significantly to the PTS.

Predictors of neurological morbidity after coronary artery bypass surgery.

OBJECTIVE: The aim of this study was to analyze the postoperative neurological complications after myocardial revascularization. METHODS: We analyzed the pre-, peri- and postoperative data of 3834 patients who underwent a primary isolated bypass grafting between January 1987 and December 1995. Postoperative neurological complications (A) were divided into mild complications (B) and major complications (C). RESULTS: The incidence of A increased, from 1.4% to 3.0%. Unifactor risk analysis identified: age > 75 years, peripheral vascular atherosclerosis, neurological pathology, aorta-pathology and perioperative myocardial infarction as risk factors for A. Perioperative myocardial infarction and neurological pathology for B; age > 75 years, peripheral vascular atherosclerosis, neurological pathology, perioperative myocardial infarction and aorta pathology for C. Multifactor risk regression analysis identified peripheral vascular atherosclerosis, neurological pathology, aorta-pathology, perioperative myocardial infarction and the time cohort 1993-1995 as independent predictors for A; perioperative myocardial infarction and the time cohort 1993-1995 for B; neurological pathology, aorta-pathology and perioperative myocardial infarction for C. CONCLUSIONS: Peripheral vascular atherosclerosis, neurological pathology, aorta-pathology, the occurrence of a perioperative myocardial infarction and the time cohort 1993-1995 are identified as independent risk factors for neurological complications.

Venous duplex scanning of the leg: range, variability and reproducibility.

Despite the many studies on venous haemodynamics using duplex, only a few evaluated the normal values, variability and reproducibility. Therefore, the range and variability of venous diameter, compressibility, flow and reflux were measured. To obtain normal values, 42 healthy individuals (42 limbs, 714 vein segments) with no history of venous disease were scanned by duplex. To determine the reproducibility the intra-observer variability was measured in 11 healthy individuals (187 vein segments) and the inter-observer variability in 15 healthy individuals (255 vein segments) and 13 patients (169 vein segments) previously diagnosed with deep venous thrombosis. Of the 714 normal vein segments, 708 (99%) were traceable, including the crural veins. Of the traceable vein segments, 675 (95%) were compressible and in 696 (98%) flow was present. Of the 42 common femoral vein segments, in 25 (60%) the reflux duration exceeded 1.0 s, but in the other proximal vein segments the reflux duration was less than 1.0 s (95% confidence interval 3.0-10.0). With the exception of the distal long saphenous vein, in the distal vein segments the reflux duration was less than 0.5 s (95% confidence interval 3.5-8.2). The coefficient of variation of the diameter measurements ranged from 14 to 50% and that of the reflux measurements from 28 to 60%. The kappa-coefficient of the inter-observer variability in the classification of compressibility measurements in the patients was 0. 77 and that of the reflux measurements was 0.86. This study shows that almost all veins were compressible in healthy individuals, except the distal femoral veins. In healthy individuals the duration of reflux of the proximal veins was less than 1.0 s and in the distal veins it was less than 0.5 s. The inter-observer variability of the reflux and compressibility measurements in the patients was good.

Coronary bypass surgery: what is changing? Analysis of 3834 patients undergoing primary isolated myocardial revascularization.

OBJECTIVE: The patient population undergoing myocardial revascularization has changed during the last few years. Knowledge of these changes, and of the subsequent influence on morbidity and/or mortality is important, not only for up-dating quality control, but also to support decision-making in financial and economical aspects, and in further research concerning coronary artery surgery. METHODS: Pre-, per- and postoperative data of 3834 primary isolated coronary bypass operations, January 1987 December 1995 were analyzed. The total group was divided into three time cohorts. Group A: 1987 1989 (n = 1292); group B: 1990-1992 (n = 1130); and group C: 1993-1995 (n = 1412). RESULTS: Mean age increased from 60.4 +/- 9.0 (S.D.) years in group A to 62.9 +/- 9.9 (S.D.) years in group C (P < 0.0005). Patients with insulin-dependent diabetic (P = 0.005), uro-nefrological (P = 0.002), pulmonary (P < 0.0005)and neurological (P = 0.003) pathology increased significantly, and there was a significant increase in the use of arterial grafts (P < 0.05). Postoperative, hospital mortality remained stable (+/- 2.5%). However, there was a significant increasing percentage of patients with pulmonary (P = 0.04), neurological (P = 0.02) and uro-nefrological (P < 0.0005) problems. CONCLUSION: During the last few years there has been a trend in myocardial revascularization of older patients, with more coexisting disease. Despite the fact that hospital mortality seems stable, there is an increase in major postoperative morbidity.

Duplex ultrasound in the hemodynamic evaluation of the late sequelae of deep venous thrombosis.

PURPOSE: The use of duplex ultrasound scanning to evaluate the hemodynamic outcome of deep venous thrombosis 7 to 13 years after the original diagnosis. METHODS: Duplex ultrasound was used to re-examine 1212 segments of vein from 72 patients (49 men, 23 women) with deep venous thrombosis previously diagnosed by means of phlebography to detect reflux and obstruction and evaluate flow; 611 segments were initially thrombosed and 601 segments were open. To define reflux, reversed flow in 31 healthy persons was measured. RESULTS: In a review of all veins of the 72 patients, 8 patients (11%) had completely normal duplex results in all veins, 33 (46%) had reflux, 6 (8%) had at least one noncompressible vein segment, and 25 (35%) had a combination of both. In the proximal vein segments without initial thrombosis a higher percentage was normal (73%) than in segments with initial thrombosis (46%). There was a significantly higher frequency of reflux (46%, p = 0.05) and noncompressibility (12%, p < 0.01) in initially thrombosed proximal vein segments than in vein segments without initial thrombosis (reflux 25%, noncompressibility 3%). Distal to the knee 125 (17%) of 720 vein segments were not traceable. Significantly more initially thrombosed vein segments were not traceable (p < 0.01). In distal vein segments there was no significant difference in reflux (7% versus 5%) and noncompressibility (10% versus 5%) between vein segments with and without initial thrombosis. Flow was present in 99% of the 611 previously thrombosed proximal and distal segments. CONCLUSIONS: Most patients with deep venous thrombosis still had venous abnormalities 7 to 13 years after the initial diagnosis. The most common abnormality was reflux. Significantly more abnormalities were found in initially thrombosed segments. The abnormalities were found in the proximal vein segments and in the distal vein segments, although less frequently in the latter.

ATP content measured by 31P NMR correlates with post-ischaemic recovery of external work output in an isolated rat heart perfused with erythrocyte suspension.

The limited capacity of the heart to survive ischaemia presents a recognized problem during open-heart surgery. In order to provide a baseline for the study of cardioprotection we subjected a series of isolated rat hearts to periods of ischaemia of increasing duration, and sought correlations between phosphate metabolite levels as measured by 11P NMR and post-ischaemic recovery of external work output. A strong linear correlation was found between the fraction of ATP measured after reperfusion expressed as a ratio. RATP to the pre-ischaemic level, and the fractional recovery of external work output, RW: Rw = 1.06 (SE 0.27) RATP + 0.01 (SE 0.21) (Spearman rank correlation coefficient 0.72, two-tailed P value 0.006).

Morbidity and mortality in 200 consecutive coronary reoperations.

OBJECTIVE: The morbidity and mortality of coronary reoperations is still higher than in primary myocardial revascularization. In the present paper we analyzed the relation between several preoperative and peroperative variables and the perioperative morbidity and mortality of coronary reoperations. METHODS: The data of 200 consecutive patients undergoing isolated aortocoronary bypass reoperation were studied by univariate and multivariate analysis. The mean age was 59 years (range 44-83 years), 163 (81%) patients were male and 37 (19%) female. The overall hospital mortality was 8.5% (17/200), and in 32/200 patients (16%) a perioperative myocardial infarction was noted. RESULTS: By univariate analysis, a myocardial infarction before the initial operation and a myocardial infarction between the initial operation and the reoperation, peripheral vascular disease, diabetes, anginal status and perioperative myocardial infarction were identified as factors influencing the operative mortality. Multivariate analysis identified perioperative myocardial infarction and anginal status as predictors of hospital mortality. Further analysis identified peripheral vascular disease, diabetes, delivery way (ante/retrograde) of cardioplegic solution, and anginal status as univariate predictors of perioperative myocardial infarction. The only significant multivariate predictor of perioperative myocardial infarction was the anginal status. CONCLUSION: The anginal status (New York Heart Association > or = IV-A) is the dominant variable in predicting the operative outcome in coronary reoperations, and a decrease of the operative mortality and perioperative infarction rate can be expected by avoiding 'so called' emergency reoperations.

Complete arterial revascularization using the mammary Y-graft.

The recent trend is to revascularize the entire heart with arterial grafts. Five selected patients were operated using the mammary Y-graft for complete arterial revascularization. The immediate postoperative courses were uneventful. One patient presented five months later with atypical angina and a string phenomenon at the distal part of the Y-graft on catheterization, without ischemic changes on stress test. The four other patients had no complaints and no ischemic changes on stress test nine months to 4.5 years later. Using the mammary Y-graft a complete arterial revascularization can be accomplished.

Coronary flow response after myocardial ischemia may predict level of functional recovery.

Is there a quantity, potentially measurable in the operating theater, which predicts rapid recovery of heart power output after surgical intervention with ischemia? We have enhanced our blood-perfused, ejecting, isolated rat heart model for use inside the magnet of an NMR spectrometer, in order to conduct fundamental research into cardioprotective techniques. To provide a baseline, we investigated the effect of normothermic ischemic insults of varying duration. Hemodynamic and metabolic data were collected, and analyzed to seek measures predictive of rapid recovery of aortic power output, which was selected as the most important measure of function. The presence of erythrocytes in the perfusate ensures that oxygen supply is sufficient to support a physiological workload, and that there is reserve coronary flow. On reperfusion, reactive hyperemia occurs: coronary flow increases to a peak, then declines to a steady value. This response was mathematically modeled, and the data for each of fifteen experiments were fitted to the model. Correlating power output recovery against time to reach peak coronary flow yielded the following equation: R = -0.45 log10tp + 1.74 where R is the ratio of power output ten minutes after reperfusion to that before the ischemic insult, and tp is the time taken to reach peak coronary flow, in seconds. The correlation is very significant (p = 0.005). In the clinic, coronary flow response on reperfusion could be used to predict the patient's need for post-operative support.

Post-ischemic 31P NMR determination of myocardial intracellular pH in vivo using ATP peak.

31P NMR allows non-invasive measurement of intracellular pH, which drops during tissue hypoxia or ischemia. Determination is usually based on the chemical shift between the inorganic phosphate (P(i)) and phosphocreatine (PCr) peaks. During reperfusion, P(i) is taken up to form PCr and ATP, and in our model at least (an isolated, working rat heart perfused with an erythrocyte suspension), the level of P(i) reduces well below the pre-ischemic level, making pH determination difficult. The chemical shifts of the three ATP peaks also depend on pH, and the level of ATP remains high during reperfusion, so these might be used to determine pH. The results of one experiment are presented in detail, showing the time course of high energy phosphate levels before, during and after a 32 min ischemic insult, and close agreement between the pH determinations from the Pi and gamma-ATP peaks can be seen. The formula used to calculate pH from the ATP peak was: pH (ATP) = 0.59 delta 2-5.0 delta + 15.9 where delta is the shift in ppm between PCr and gamma-ATP. All pH readings by both methods from a series of seven experiments were compared and a 1:1 agreement demonstrated (correlation coefficient 0.63, p < 0.0001). Although the ATP shifts also depend on magnesium complexation which we have ignored, this appears to be justifiable within the errors of the method; the good agreement between the results of the two methods, and the ability to determine pH during reperfusion suggest that calculation of intracellular pH from the chemical shift of gamma-ATP is a useful technique.

Surgical repair of subacute left ventricular free wall rupture.

BACKGROUND: The natural course of subacute ventricular free wall rupture (FWR) as a complication of acute myocardial infarction (MI) is usually lethal. The aim of this study was to investigate the curability of this entity and to report on five patients successfully treated by rapid diagnosis, hemodynamic stabilization, and emergency surgical repair. METHODS: Five patients with subacute FWR of the left ventricle after previous MI were operated on. Infarctectomy with subsequent closure of the ruptured area was carried out in two patients with anterolateral infarction. Three other patients (two with posterior and one with lateral infarction) were treated by direct closure and the application of a patch. Furthermore, in two patients, concomitant myocardial revascularization was performed. RESULTS: All patients survived the procedure and were alive and well at long-term follow-up (mean 36.4 months). None of the patients suffered recurrent MI. CONCLUSIONS: Our experience and a review of the literature shows that prompt diagnosis and emergency surgical intervention may save the patient. Anterior rupture (with a moderate sized infarcted area) is best treated by infarctectomy and subsequent closure of the ventriculotomy with sutures buttressed with felt, whereas posterior rupture may be treated by direct closure and the application of an epicardial patch. Considering our results, we cannot conclude whether additional coronary artery bypass grafting is beneficial or not. Our suggestion is to perform additional myocardial revascularization only if indicated.

Doppler spectrum analysis in the differential diagnosis of renal transplant dysfunction.

Cyclosporin A (CyA) nephrotoxicity and rejection of a renal allograft each demands a specific therapy. This study was designed to establish the capability of Doppler spectrum analysis to diagnose either one of these causes during renal dysfunction. Between October 1989 and October 1991 we performed echo-Doppler examinations in 209 renal transplant recipients on a routine basis during the first three months after transplantation. Echo-Doppler examinations during periods of renal dysfunction were analyzed. A total of 93 periods of renal dysfunction, retrospectively due to rejection (n = 40) or CyA toxicity (n = 53), occurred in 70 patients during the study period. A control group consisted of 82 patients with normal functioning grafts. When compared to the control group, the Doppler features (in segmental arteries) of the rejection group showed significant lower frequency shifts [Fmax (Hz) 1637 +/- 423 vs. 1436 +/- 465; p < 0.05; Fdia (Hz) 582 +/- 180 vs. 458 +/- 225; p < 0.05], a shorter deceleration time of the Doppler spectrum [Tdown (ms) 340 +/- 100 vs. 276 +/- 102; p < 0.05], and a higher Resistance Index (RI 0.64 +/- 0.08 vs. 0.68 +/- 0.13; p < 0.05). Doppler spectra during CyA toxicity showed only a significantly longer acceleration time [Tmax (ms) 123 +/- 36 vs. 139 +/- 40; p < 0.05]. The capability of differentiation between the two causes was assessed with ROC analysis of single Doppler features, stepwise regression and canonic discriminant analysis on a set of Doppler features and with manual selection of several features with extreme values. ROC analysis yielded maximum sensitivity and specificity for the diagnosis of rejection using Tdown (sensitivity 65%; specificity 68%). Stepwise regression and canonic discriminant analysis of a set of features rendered a sensitivity and specificity of 73% and 64%, respectively. Explorative selection of extreme Doppler feature values showed that 18 of the 40 grafts with rejection had values that were only seen in 2 cases with CyA toxicity (positive predictive value 90%; sensitivity 45%; specificity 96%). In half of these cases Doppler features preceded the clinical diagnosis of rejection by a median of 4 d. In conclusion, Doppler spectra are influenced by rejection and CyA toxicity in specific ways. The Doppler features, however do not enable definite differentiation between rejection and CyA toxicity in all cases. Some changes in Doppler spectra are only seen in cases of rejection and thus enable positive identification of grafts with rejection, often earlier than clinical signs indicate rejection. A normal Doppler spectrum does not exclude rejection as the cause of renal dysfunction.