Utility of long-term surveillance endomyocardial biopsy: a multi-institutional analysis
J Stehlik1, R C Starling, M A Movsesian
1Cardiology Section, University of Utah School of Medicine, VA Salt Lake City Health Care System, Salt Lake City, Utah 84148, USA. josef.stehlik@hsc.utah.edu
Insights
Long-term heart transplant surveillance biopsies offer limited benefits beyond five years. However, surveillance between two and five years can reduce mortality in African-American recipients and high-risk patients.
Area of Science:
- Cardiology
- Transplant Medicine
- Immunology
Background:
- The clinical utility of long-term endomyocardial biopsy surveillance in heart transplant recipients remains debated.
- Identifying risk factors for late rejection and evaluating surveillance protocols are crucial for optimizing patient outcomes.
Purpose of the Study:
- To identify risk factors associated with late rejection after heart transplantation.
- To assess the impact of varying endomyocardial biopsy surveillance protocols on patient outcomes.
Main Methods:
- Analysis of adult heart transplant recipients from the Cardiac Transplant Research Database (1993-2002).
- Inclusion criteria: survival past two post-transplant years with a defined surveillance biopsy protocol.
- Data collected over 24,137 patient-years, documenting 1,626 late rejection events.
Main Results:
- Shorter time since transplant, prior rejection history, younger recipient age, and African-American ethnicity were significant risk factors for late rejection.
- Continued surveillance increased the diagnosis rate of late rejection (RR=1.3, p=0.002) but did not reduce hemodynamically compromising rejection or improve survival compared to intermediate-term surveillance.
- Short-term surveillance correlated with increased hemodynamically compromising rejection and mortality, especially in African-American patients.
Conclusions:
- Surveillance biopsies beyond five years post-transplant show no clear benefit.
- Biopsy surveillance between two and five years post-transplant is associated with reduced mortality in African-American recipients.
- High-risk non-African-American recipients may benefit from surveillance up to five years post-transplant.
Background:
The utility of long-term endomyocardial biopsy surveillance in heart transplant recipients has been questioned. This study was undertaken to identify risk factors for late rejection and to examine the impact of different biopsy surveillance protocols on outcomes using the registry of the Cardiac Transplant Research Database.
Methods:
The study group consisted of all adult patients who underwent heart transplantation at the 33 centers participating in this investigation between January 1, 1993 and January 1, 2002, survived past the second post-transplant year, and were followed-up by a defined surveillance biopsy protocol.
Results:
During a follow-up that consisted of 24,137 patient-years, 1,626 late rejections occurred. Shorter time since transplant, history of rejection, younger age and African-American ethnicity of the recipient were strong risk factors for late rejection. The practice of surveillance biopsy varied among institutions. Continued surveillance increased the rate of diagnosis of late rejection (RR = 1.3, p = 0.002). There was no reduction in the incidence of hemodynamically compromising rejection and no increase in survival in patients with long-term vs intermediate-term surveillance. Short-term surveillance was associated with an increased incidence of hemodynamically compromising rejection, particularly among high-risk patients, and increased mortality in African-American patients.
Conclusions:
There are no apparent benefits from surveillance biopsy beyond 5 years post-transplant. Surveillance biopsy between 2 and 5 years post-transplant was found to reduce mortality in African-American recipients. Non-African-American recipients at high risk for late rejection will likely benefit from surveillance up to 5 years post-transplant.
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