Key result
For cause endomyocardial biopsies yielded a significantly higher rate of treated acute rejection compared to surveillance biopsies (14.2% vs 1.2%, OR 9.17), demonstrating a superior benefit-to-risk ratio.
Why the study?
The benefit of diagnosing and treating acute rejection compared to the risk of EMB complications has not been compared in the contemporary era.
Does for cause endomyocardial biopsy improve the benefit/risk ratio of detecting treated acute rejection compared to surveillance biopsy in adult heart transplant patients?
Observational (n=326)
No
Does for cause endomyocardial biopsy improve the benefit/risk ratio of detecting treated acute rejection compared to surveillance biopsy in adult heart transplant patients?
Odds Ratio: 9.17 (95% CI 4.56–18.46)
Absolute Event Rate: 14.2% vs 1.2%
p-value: p=<0.001
In the contemporary era, the yield of surveillance endomyocardial biopsies in heart transplant patients has declined such that the risks of complications outweigh the benefits, particularly within the first month post-transplant.
Surveillance EMB linked to inferior benefit-risk versus for-cause; leaves open whether routine protocols warrant revision in contemporary heart transplant care.
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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Cusi et al. (2023) conducted an observational in Heart transplant (n=326). For cause endomyocardial biopsy vs. Surveillance endomyocardial biopsy was evaluated on Treated acute rejection (OR 9.17, 95% CI 4.56-18.46, p=<0.001). For cause endomyocardial biopsies yielded a significantly higher rate of treated acute rejection compared to surveillance biopsies (14.2% vs 1.2%, OR 9.17), demonstrating a superior benefit-to-risk ratio.
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