title: Limited utility of endomyocardial biopsy in the first year after heart transplantation.
abstract: BACKGROUND
  Surveillance endomyocardial biopsies (EMBs) are used for the early diagnosis of acute cardiac allograft rejection. Protocols became standardized in an earlier era and their utility with contemporary immunosuppression has not been investigated.
  
  
  METHODS
  We studied 258 patients after orthotopic heart transplantation comparing 135 patients immunosuppressed by mycophenolate mofetil (MMF) with 123 patients treated by azathioprine (AZA); both with cyclosporine and corticosteroids after induction therapy with rabbit antithymocyte globulin. Fifteen EMBs were scheduled in the first year. Additional EMBs were performed for suspected rejection, after treatment, or for inadequate samples. The MMF group had 1875 EMBs vs. 1854 in the AZA group.
  
  
  RESULTS
  The yield of International Society for Heart and Lung Transplantation (ISHLT) grade> or =3A biopsy-proven acute rejection (BPAR) was 1.87% per biopsy (35 of 1875) with MMF vs. 3.13% (58 of 1854) with AZA P=0.024. The number of clinically silent BPAR ISHLT grade > or =3A (the true yield of surveillance EMBs) was 1.39% (26 of 1875) of biopsies MMF vs. 2.1% (39 of 1854) AZA, P=0.48. There were five serious complications requiring intervention or causing long-term sequelae; 0.13% (5 of 3729) per biopsy and 1.94% (5 of 258) per patient. The incidence of all definite and potential complications was 1.42% (53 of 3729) per biopsy and 20.5% (53 of 258) per patient. There was no biopsy-related mortality.
  
  
  CONCLUSIONS
  The yield of BPAR was low in the AZA group and very low in the MMF group. The incidence of complications was also low, but repeated biopsies led to a higher rate per patient. Routine surveillance EMBs and the frequency of such biopsies should be reevaluated in the light of their low yield with current immunosuppression.
authors.affiliation: Department of Cardiology, the Royal Brompton and Harefield NHS Trust, Harefield Hospital, Harefield, Middlesex UB9 6JH, United Kingdom.
authors.forename: Iman M
authors.initials: IM
authors.lastname: Hamour
authors.forename: Margaret M
authors.initials: MM
authors.lastname: Burke
authors.forename: Alex D
authors.initials: AD
authors.lastname: Bell
authors.forename: Mathen G
authors.initials: MG
authors.lastname: Panicker
authors.forename: Rajasi
authors.initials: R
authors.lastname: Banerjee
authors.forename: Nicholas R
authors.initials: NR
authors.lastname: Banner
mesh_terms: D001706:Biopsy / Q000009:adverse effects*; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000453:epidemiology / Q000473:pathology; D016027:Heart Transplantation / Q000473:pathology*; D006801:Humans; D009206:Myocardium / Q000473:pathology; D011183:Postoperative Complications / Q000453:epidemiology / Q000473:pathology; D011336:Probability; D015203:Reproducibility of Results; D012189:Retrospective Studies; D018570:Risk Assessment; D013997:Time Factors