title: Utility of long-term surveillance endomyocardial biopsy: a multi-institutional analysis.
abstract: BACKGROUND
  The utility of long-term endomyocardial biopsy surveillance in heart transplant recipients has been questioned. This study was undertaken to identify risk factors for late rejection and to examine the impact of different biopsy surveillance protocols on outcomes using the registry of the Cardiac Transplant Research Database.
  
  
  METHODS
  The study group consisted of all adult patients who underwent heart transplantation at the 33 centers participating in this investigation between January 1, 1993 and January 1, 2002, survived past the second post-transplant year, and were followed-up by a defined surveillance biopsy protocol.
  
  
  RESULTS
  During a follow-up that consisted of 24,137 patient-years, 1,626 late rejections occurred. Shorter time since transplant, history of rejection, younger age and African-American ethnicity of the recipient were strong risk factors for late rejection. The practice of surveillance biopsy varied among institutions. Continued surveillance increased the rate of diagnosis of late rejection (RR = 1.3, p = 0.002). There was no reduction in the incidence of hemodynamically compromising rejection and no increase in survival in patients with long-term vs intermediate-term surveillance. Short-term surveillance was associated with an increased incidence of hemodynamically compromising rejection, particularly among high-risk patients, and increased mortality in African-American patients.
  
  
  CONCLUSIONS
  There are no apparent benefits from surveillance biopsy beyond 5 years post-transplant. Surveillance biopsy between 2 and 5 years post-transplant was found to reduce mortality in African-American recipients. Non-African-American recipients at high risk for late rejection will likely benefit from surveillance up to 5 years post-transplant.
authors.affiliation: Cardiology Section, University of Utah School of Medicine, VA Salt Lake City Health Care System, Salt Lake City, Utah 84148, USA. josef.stehlik@hsc.utah.edu
authors.forename: J
authors.initials: J
authors.lastname: Stehlik
authors.forename: R C
authors.initials: RC
authors.lastname: Starling
authors.forename: M A
authors.initials: MA
authors.lastname: Movsesian
authors.forename: J C
authors.initials: JC
authors.lastname: Fang
authors.forename: R N
authors.initials: RN
authors.lastname: Brown
authors.forename: M L
authors.initials: ML
authors.lastname: Hess
authors.forename: N P
authors.initials: NP
authors.lastname: Lewis
authors.forename: J K
authors.initials: JK
authors.lastname: Kirklin
mesh_terms: D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data; D001706:Biopsy; D002319:Cardiovascular System / Q000503:physiopathology; D004699:Endocardium / Q000473:pathology*; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000453:epidemiology / Q000209:etiology; D016027:Heart Transplantation / Q000009:adverse effects* / Q000208:ethnology; D006801:Humans; D007165:Immunosuppression Therapy; D015994:Incidence; D008875:Middle Aged; D009206:Myocardium / Q000473:pathology*; D011159:Population Surveillance / Q000379:methods*; D011184:Postoperative Period; D012042:Registries; D012307:Risk Factors; D016019:Survival Analysis; D013997:Time Factors