Benefit versus Risk of Endomyocardial Biopsy for Heart Transplant Patients in the Contemporary Era
Insights
Routine surveillance endomyocardial biopsies (EMBs) in heart transplant (HTx) patients yield low benefit and carry risks, especially within the first month post-transplant. For-cause EMBs remain valuable for detecting acute rejection.
Area of Science:
- Cardiology
- Transplant Surgery
- Pathology
Background:
- Endomyocardial biopsy (EMB) is the gold standard for detecting acute rejection (AR) in adult heart transplant (HTx) patients.
- Most EMBs are performed electively in asymptomatic patients.
- The contemporary benefit versus risk of EMBs for AR detection has not been well-established.
Approach:
- Retrospective analysis of 2,769 EMBs from 326 HTx patients (August 2019 - August 2022).
- Compared outcomes based on surveillance versus for-cause indications.
- Evaluated EMB procedural data, AR treatment rates, and clinical outcomes.
Key Points:
- Overall EMB complication rate was 1.6%, with significantly higher risks within 1 month post-HTx (OR=12.74).
- Treated AR rates were 14.2% for for-cause EMBs vs. 1.2% for surveillance EMBs.
- Benefit/risk ratio was significantly lower for surveillance EMBs (OR=0.05), indicating risk outweighed benefit.
Conclusions:
- The diagnostic yield of surveillance EMBs has decreased in the current era.
- For-cause EMBs continue to offer a favorable benefit/risk profile for AR detection.
- Current surveillance EMB protocols require re-evaluation, particularly regarding timing and necessity.
Background:
The reference standard of detecting acute rejection (AR) in adult heart transplant (HTx) patients is an endomyocardial biopsy (EMB). The majority of EMBs are performed in asymptomatic patients. However, the benefit of diagnosing and treating AR compared to the risk of EMB complications has not been compared in the contemporary era (2010-current).
Methods:
The authors retrospectively analyzed 2,769 EMB obtained in 326 consecutive HTx patients between August 2019 and August 2022. Variables included surveillance versus for cause indication, recipient and donor characteristics, EMB procedural data and pathologic grades, treatment for AR, and clinical outcomes.
Results:
The overall EMB complication rate was 1.6%. EMBs performed within 1 month after HTx compared to after 1 month from HTx showed significantly increased complications (OR = 12.74, p < 0.001). The treated AR rate was 14.2% in the for cause EMBs and 1.2% in the surveillance EMBs. We found the benefit/risk ratio was significantly lower in the surveillance compared to the for cause EMB group (OR = 0.05, p < 0.001). We also found the benefit to be lower than risk in surveillance EMBs.
Conclusions:
The yield of surveillance EMBs has declined, while for cause EMBs continued to demonstrate a high benefit/risk ratio. The risk of EMB complications was highest within 1 month after HTx. Surveillance EMB protocols in the contemporary era may need to be re-evaluated.
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