Beyond the virtual biopsy: a risk-adaptive CMR pathway for precision heart-transplant surveillance

Taipale et al.1 deserve commendation for advancing one of the most consequential ambitions in transplant imaging: replacing routine procedural surveillance with biologically informative, non-invasive assessment. Their prospective study demonstrates excellent diagnostic performance of global cardiovascular magnetic resonance (CMR) T1 mapping for acute rejection across paediatric and adult heart-transplant recipients and suggests that a substantial proportion of routine endomyocardial biopsies (EMBs) might potentially be avoided. Rather than viewing these findings simply as another step towards a ‘virtual biopsy’, we believe they invite a more transformative question: can CMR become the organizing tissue-phenotyping layer of a risk-adaptive surveillance system? This possibility is compelling because CMR need not function in isolation. Prospective evidence has already demonstrated the feasibility of CMR-based rejection surveillance while substantially reducing dependence on routine EMB,2 and subsequent work has linked T1/T2 abnormalities with histological, clinical, functional, and donor-derived cell-free DNA (dd-cfDNA) evidence of allograft injury.3 Nevertheless, replacing one gatekeeper with another would be premature. Elevated dd-cfDNA may indicate allograft injury without independently resolving its mechanism,4 while CMR thresholds remain vulnerable to differences in acquisition, platform, calibration, age, and biological context.1 The opportunity, therefore, is not CMR vs. biopsy, but intelligent integration.