Abstract
In heart transplantation (HTx) patients, routine surveillance endomyocardial biopsies (rsEMB) are recommended for the detection of early cardiac allograft rejection. However, there is no consensus on the optimal frequency of rsEMB. Frequent rsEMB have shown a low diagnostic yield in the new era of potent immunosuppressive regimen. Efficacy and safety of lower frequency rsEMB have not been investigated so far. In this retrospective, single centre, observational study we evaluated 282 patients transplanted between 2004 and 2014. 218 of these patients were investigated by rsEMB and symptom-triggered EMB (stEMB). We evaluated EMB results, complications, risk factors for rejection, survival 1 and 5 years as well as incidence of cardiac allograft vasculopathy (CAV) 3 years after HTx. A mean of 7.1 ± 2.5 rsEMB were conducted per patient within the first year after HTx identifying 7 patients with asymptomatic and 9 patients with symptomatic acute rejection requiring glucocorticoide pulse therapy. Despite this relatively low frequency of rsEMB, only 6 unscheduled stEMB were required in the first year after HTx leading to 2 additional treatments. In 6 deaths among all 282 patients (2.1%), acute rejection could not be ruled out as a potential underlying cause. Overall survival at 1 year was 78.7% and 5-year survival was 74%. Incidence of CAV was 17% at 3-year follow-up. Morbidity and mortality of lower frequency rsEMB are comparable with data from the International Society for Heart and Lung Transplantation (ISHLT) registry. Consensus is needed on the optimal frequency of EMB.
Highlights
Routine surveillance endomyocardial biopsies are considered to be important to detect acute rejection after heart transplantation (HTx) [1]
Between January 2004 and November 2014, a total of 282 patients were transplanted at our centre. 53 patients died before the first EMB and 11 patients were not investigated by Routine surveillance endomyocardial biopsies (rsEMB)
In the cohort with rsEMB (n = 218), initial treatment regimen consisted of tacrolimus/mycophenolate mofetil (TAC/MMF) in 187 patients (86%), TAC/mammalian target of rapamycin inhibitor with a combination of TAC with either sirolimus (SIR) or everolimus (EVE) in 27 patients (12%), calcineurin inhibitorfree immunosuppression (CNI-free, combination of SIR/MMF or EVE/MMF) in 3 patients (1%) and TAC/azathioprine (AZA) in 1 patient
Summary
Routine surveillance endomyocardial biopsies (rsEMB) are considered to be important to detect acute rejection after heart transplantation (HTx) [1]. The working formulation for acute cellular rejections, originally defined in 1990, has been revised in 2004. Lower frequency surveillance biopsies after heart transplantation moderate rejection (reflecting former grade 3A) and grade 3R for severe rejection (summarizing former grade 3B and 4) [2]. According to the International Society for Heart and Lung Transplantation (ISHLT) guidelines, symptomatic grade 1R rejections or rejections ! The incidence of early acute cellular rejection after heart transplantation decreased significantly during the last two decades. Grade 3A rejections in 45–52.9% after a 6-month follow-up in their randomized study on mycophenolate mofetil (MMF) [4]. Grade 3A rejections at 1-year follow-up of only 20.7–29.3% [5] Hamour et al revealed a cumulative incidence of ! grade 3A rejections at 1-year follow-up of only 20.7–29.3% [5]
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