Endomyocardial Biopsy beyond 2 Years after Cardiac Transplantation: Clinical Implications and Cost Analysis

Objectives: Endomyocardial biopsy (EMB) is considered as the gold standard method to identify rejection after heart transplantation. However, it`s routine use beyond the first year after transplantation remains controversial. A previous study revealed a higher rate of ACR in the long term in calcineurin inhibitor (CNI) free patients. The aim of the present study was to determine the incidence of late graft rejection in all routine surveillance biopsies and cost-analysis in long term follow up after heart transplantation.

Methods: From 2000 to 2018, a total of 220 patients underwent cardiac transplantation in our hospital. Clinical characteristics and data were collected from all long-term survivors (> 2 years, n = 151) and included in this retrospective study. Significant cellular rejection was defined as grade 2R or 3R using ISHLT grading criteria. Late rejection incidence was recorded for patients who underwent routine surveillance EMB after 2 years post-HT. We analyzed the immunosuppressive regimen of these patients and the costs of long term EMB.

Result: We analyzed 2,940 endomyocardial biopsies performed over 20 years with overall low complication rate (<1%). 26 patients of all long-term survivors (17.2%) developed at least one episode of moderate or severe cellular rejection (2/3R) detected in routine surveillance biopsies. However, despite earlier findings the immunosuppressive regimen did not impact the rate of late ACR (57.7% CNI vs. 42.3% CNI free). Therapy included immunosuppressive switch and IV corticosteroid treatment.

Conclusion: Endomyocardial biopsies continue to detect clinically significant rejection beyond 2 years after heart transplantation. Late graft rejection is not depending on previous episodes of early cellular rejection nor on the immunosuppressive regimen. We therefore still recommend surveillance biopsies in all cardiac transplant recipients.

Publication History

Article published online:
19 February 2021