title: Role of endomyocardial biopsy in rejection surveillance after heart transplantation in neonates and children.
abstract: OBJECTIVE
  The aim of this study was to retrospectively evaluate the sensitivity of noninvasive surveillance (physical examination, echocardiography) of rejection in accurately predicting histologically documented rejection episodes. Additionally, the usefulness of routine scheduled biopsy and its safety in pediatric patients was explored.
  
  
  BACKGROUND
  Endomyocardial biopsy has been utilized as the standard for rejection surveillance after heart transplantation in adults, but its role in documenting clinically suspected rejection and in routine surveillance of pediatric patients has not been agreed upon.
  
  
  METHODS
  Heart transplantation was performed in 14 neonates and 21 children. The immunosuppressive regimen consisted of cyclosporine, azathioprine and prednisone. All patients underwent routine noninvasive rejection surveillance that included clinical examination and echocardiography. In the neonates, biopsy was performed quarterly beginning 6 months after transplantation, after cessation of prednisone therapy. In the children, biopsy was performed 15 times in the 1st year. A minimum of five biopsy samples were interpreted using the Working Formulation for Heart Transplant Rejection.
  
  
  RESULTS
  In the neonates, 37 biopsies were performed. Evidence of rejection was present in only three biopsy samples obtained during eight episodes (38%) of clinically suspected rejection. In 29 biopsies performed when rejection was not clinically suspected, each biopsy was free of cellular infiltrate. In the children, 291 biopsies were performed. Evidence of rejection was present in only seven biopsies (41%) from 17 episodes of clinically suspected rejection. Cellular rejection was discovered during routine rejection surveillance biopsies in asymptomatic patients in 23 (8.4%) of 274 biopsies.
  
  
  CONCLUSIONS
  In neonates with clinically suspected rejection, endomyocardial biopsy identified which patients did not require rejection therapy. Endomyocardial biopsy surveillance did not detect any unsuspected cases of rejection. In children, noninvasive rejection surveillance was less reliable even in asymptomatic patients, suggesting that periodic endomyocardial biopsy should be utilized.
authors.affiliation: Division of Cardiology, Children's Memorial Hospital, Chicago, Illinois 60614.
authors.forename: V R
authors.initials: VR
authors.lastname: Zales
authors.forename: S
authors.initials: S
authors.lastname: Crawford
authors.forename: C L
authors.initials: CL
authors.lastname: Backer
authors.forename: E
authors.initials: E
authors.lastname: Pahl
authors.forename: C L
authors.initials: CL
authors.lastname: Webb
authors.forename: P
authors.initials: P
authors.lastname: Lynch
authors.forename: C
authors.initials: C
authors.lastname: Mavroudis
authors.forename: D W
authors.initials: DW
authors.lastname: Benson
mesh_terms: D001706:Biopsy; D002648:Child; D004452:Echocardiography; D004699:Endocardium / Q000473:pathology*; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000175:diagnosis* / Q000453:epidemiology; D016027:Heart Transplantation / Q000276:immunology* / Q000473:pathology; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007231:Infant, Newborn; D009206:Myocardium / Q000473:pathology*; D010808:Physical Examination; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D015996:Survival Rate; D013997:Time Factors
chemical_list: D007166:Immunosuppressive Agents