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Routine surveillance myocardial biopsies are unnecessary beyond one year after heart transplantation
J A White1, C Guiraudon, P W Pflugfelder
1Department of Medicine (Cardiology), University Hospital, University of Western Ontario, London, Canada.
Insights
Routine annual heart biopsies rarely detect rejection after one year post-transplant. A selective approach based on clinical status is more effective for managing heart transplant patients.
Area of Science:
- Cardiology
- Transplantation Medicine
- Immunology
Background:
- Myocardial rejection is a primary concern in the initial 90 days post-heart transplant.
- Indefinite, regular surveillance endomyocardial biopsies are common, but their clinical benefit is unclear.
- This study evaluates the utility of routine annual biopsies in long-term heart transplant recipients.
Purpose of the Study:
- To determine the frequency of abnormalities in routine annual endomyocardial biopsies.
- To assess the influence of these biopsies on patient management beyond the first year post-transplantation.
Main Methods:
- Reviewed 1123 endomyocardial biopsies from 235 heart transplant recipients surviving over 1 year.
- Analyzed the incidence of late rejection and Quilty effect (lymphocytic aggregates).
- Assessed therapeutic responses to biopsy findings.
Main Results:
- Only 0.6% of biopsies (7 out of 1123) showed significant rejection (grade ≥2) beyond one year.
- The Quilty effect was present in 27.6% of specimens.
- No deaths were predicted by routine surveillance biopsies; a selective approach is suggested.
Conclusions:
- Significant myocardial rejection is infrequent more than one year after heart transplantation.
- Routine annual endomyocardial biopsies have minimal impact on patient management beyond the first year.
- A selective strategy for biopsies, guided by clinical changes, is clinically justified.
Background:
Myocardial rejection is most apt to occur in the first 90 days after heart transplantation. Nevertheless, surveillance endomyocardial biopsies are often performed on a regular basis, indefinitely. The benefit of this approach to patient management is uncertain. Our objective was to determine the frequency of abnormalities and the influence of a routine annual endomyocardial biopsy on patient management.
Methods:
In a consecutive series of 235 transplant recipients who survived 1 year or more, the results of 1123 routine endomyocardial biopsies performed 1 year or more after transplantation were reviewed. The incidence of late rejection, presence of Quilty effect (focal endocardial or myocardial lymphocytic aggregates), and therapeutic reaction to the biopsy result were analyzed.
Results:
Of 1123 biopsy specimens in 235 patients (1 to 12 years after transplantation), 1115 (99.3%) showed no evidence of significant rejection (grade 0 or 1). Only seven (0.6%) had evidence of rejection grade 2 or worse. Of the seven abnormal biopsy specimens in seven patients, two occurred at 1 year, two at 2 years, and one each at 4, 7, and 8 years. Of these, six were treated for rejection with an increase in the immunosuppressive therapy. One patient was identified as having a symptomatic condition at the time of biopsy. A focal endocardial or myocardial accumulation of lymphocytes (Quilty effect) was present in 311 biopsy specimens (27.6%). Beyond 1 year, 33 patients died, 14 because of graft vascular disease with or without rejection and 19 because of other causes. No deaths were predicted on the basis of a routine surveillance biopsy.
Conclusions:
Myocardial rejection is rare beyond 1 year after transplantation. The routine endomyocardial biopsy does not significantly impact patient management beyond 1 year. A selective approach to myocardial biopsies, on the basis of a change in clinical status or immunosuppressive medications, is justified.