Should we be doing routine biopsy after heart transplantation in a new era of anti-rejection?
OBJECTIVE
The endomyocardial biopsy has defined the diagnosis of rejection in cardiac transplantation and has historically been a vital tool when rejection rates following transplantation were high. Surveillance biopsies have been the cornerstone of post-transplant management, as signs or symptoms of rejection are non-specific. With significant improvements in immunosuppressive therapy, however, the incidence of clinically significant rejection has declined, bringing into question the need for routine surveillance biopsy. This article reviews the current role of the endomyocardial biopsy in the management of patients following cardiac transplantation.


RESULTS
The endomyocardial biopsy is also limited by sub-optimal interobserver reproducibility, a lack of consensus with regard to treating certain grades of rejection, and often a lack of histological findings in patients with hemodynamic compromise, which frequently responds to anti-rejection therapy. Recent refinements, however, have allowed improved diagnosis of antibody mediated rejection, a relatively recently recognized entity. Moreover, a number of non-invasive modalities have been investigated recently as potential substitutes for the endomyocardial biopsy in detecting rejection.


CONCLUSIONS
Despite the development of a variety of non-invasive methods for the detection of rejection, the endomyocardial biopsy will remain important in the management of patients following cardiac transplantation, as non-invasive techniques are associated with low specificity for the diagnosis of rejection. A new standardized classification will likely improve the utility of the biopsy by simplifying interpretation of cellular rejection and importantly allowing recognition of antibody-mediated rejection.
Division of Cardiology, The David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California 90095, USA.
Jignesh K
JK
Patel
Jon A
JA
Kobashigawa
D001706:Biopsy; D004699:Endocardium / Q000473:pathology*; D006084:Graft Rejection / Q000175:diagnosis / Q000473:pathology* / Q000517:prevention & control*; D006333:Heart Failure / Q000473:pathology / Q000601:surgery*; D016027:Heart Transplantation / Q000473:pathology*; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D009206:Myocardium / Q000473:pathology*; D032383:Myocytes, Cardiac / Q000473:pathology; D015588:Observer Variation; D012680:Sensitivity and Specificity
D007166:Immunosuppressive Agents